l\ 


I 


ERRATA. 

Page  201,  line  5,  after  "reach  grasp"  insert  "step." 

„     209,  ,,  1,  "bones,  &o."  sliould  be  omitted. 

„     262,  „  18,  for  37'  read  98-6\ 

,,     323,  ,,  2  should  be  omitted. 

,,     460,  ,,  6  from  bottom,  for  "  mu.soulo-spinal  "  read  "  musculo-apiral.' 


THE    ELEMENTS   OF 
KELLGREN'S   MANUAL  TREATMENT 


EDGAR    F.    CYEIAX 

M.D.Edmburgh,  1001 ;  Gymnastic  Director,  StocMiolm,  1899 


NEW    YORK 
WILLIAM     WOOD     AND     COMPANY 

MDCCCCIV 


6^ 


librae' 


LONDON 
.'S  AND    DANlRLSaON,    L  I'! 
PHFIELD   STRKKT,    W. 


DEDICATED 

TO 

HENBIK      KELLGREN. 


35SSS9 


LlSr    OF    ILLUSTRATIONS. 


FIG. 
1 


Standing  position    . . 

Sitting  position 

Lying  position 

Kneeling  position    .  . 

Hanging  position     . . 

Bend  standing  position 

Stretch  stride  standing  position    .  . 

Yard  standing  position 

Hips  firm  knee  bend  standing  position 

Walk  standing  position 

Sit  lying  position    .  . 

Crook  lying  position 

Crook  half  lying  position    . . 

Forwards  lying  position 

Side  lying  position  . . 

Forearm  flexion  (forearm  pronated),  AR 

Reach  grasp  stoop  fall  standing  double  elbow  flexion  and  extension 

PA  

Forearm  flexion  (forearm  supinated),  AR 

Heave  sitting  double  forearm  extension  and  flexion,  AR 

Finger  flexion,  AR  . . 

Lying  leg  flexion,  PR,  extension,  AR 

Lying  leg  flexion,  AR,  extension,  PR 

Forwards  lying  leg  flexion,  PP,  raising,  AR 

Half  lying  leg  flexion,  PP,  extension,  AR 

Sit  lying  knee  extension  and  flexion,  PP 

Half  lying  foot  flexion  and  extension,  AR 

Half  lying  double  foot  flexion  and  extension,  AR 

Reach  grasp  standing  head  flexion,  PR,  extension,  AR 

Arch  forwards  lying  head  flexion,  PR,  extension,  AR  . 

Head  flexion  laterally,  AR 

Head  extension,  lateral  flexion,  and  rotation,  PR 

Ride  sitting  trunk  flexion,  PR,  extension,  AR    . . 

Ride  fall  sitting  breathing,  PA 

Forwards  lying  back  raising  (arching)  breathing,  PA    . 

Head  loan  arch  standing  toe  raising,  breathing,  PA 

Stretch  stride  standing  bending  sideways,  PA    .  . 

Hip  lean  walk  standing  lateral  flexion,  PP,  extension,  .VR 

Loin  lean  stride  standing  ringing,  PP 

Ride  sitting  double  arm  abduction,  AR,  adduction,  PR 

Swim  sitting  double  elbow  pressing  downwards,  PR,  upwards,  AR 

Halt  lying  double  arm  bending  and  stretching,  AR 

Side  lying  leg  lifting,  AR,  pressing  down,  PR     .  . 

Lying  double  leg  flexion,  PA,  abduction,  AR,  adduction,  PR 

Crook  half  lying  double  knee  abduction,  AR,  adduction,  PR  . . 


PAGE 
15 
15 
15 
17 
17 
18 
18 
20 
20 
20 
2.3 
24 
24 
25 
25 


76 

77 
70 
80 
81 
85 
8() 
87 
90 
92 
92 
94 
95 
96 


LIST  OF   ILLUSTRATIONS 


FIG. 

45 

40 

47 

48 

49 

50 

51 

52 

53 

54 

55 


Head  rotation 

Loin  lean  stride  standing  alternate  rotation,  AB 

Supination,  AR,  pronation,  PR     . . 

Sitting  arm  circling,  PP 

Sitting  hand  rolling,  PP 

Finger  rolling,  PP    .  . 

Ride  sitting  screw  turning.  PI' 


Arm  traction  sideways,  PP 

Stretch  half  lying  double  hand  and  foot  traction,  PP    . . 

,,        side  lying  hand  and  foot  traction,  PP    . . 
High  sitting  double  arm  carrying  outwards,  AR,  inwards,  PR 
Stretch  grasp  standing  drawing  forwards,  PP     .  . 
Side  span  standing  drawing  sideways,  PP 

Loin  lean  stride  standing  drawing  backwards,  PR,  forwards,  AR 
Low  sitting  chest  lifting  (expansion!,  PP 
Heave  lean  standing  chest  expansion,  PA 
Stretch  grasp  toe  standing  hanging,  breathing,  PA 

Sitting  head  lifting,  PP 

Graphic  representation  of  shakings  from  wrist  and  finger- joints 

,,  ,,  ,,  ,,      wrist  and  shoulder-joints 

Suction  vibrations  . . 
Graphic  representation  of  vibrations  from  fingers 

,,  ,,  „  ,,     wrist  and  fingers 

Half  lying  vibration  over  the  bladder,  coronal  suture  \ibration,  PP . 
Diagram  of  forwards  lying  rimning  nerve  frictions,  PP 

,,  stretch  side  lying  running  nerve  frictions,  PP 

,,  stretch  half  lying  running  nerve  frictions,  PP 

Heave  grasp  standing  side  shaking,  PP  .  . 

,.  ,,  ,,         heart  shaking.  PP 

,,  ,,  ,,         subcostal  shaking,  PP 

Back  hacking,  PP 

Chest  clapping,  PP 

Reach  grasp  step  standing  knee  flexion  and  extension,  PA,  sacral 

beating,  PP 
Standing  vertebral  coluinn  stretching,  AR  at  patient's  head    .  . 

,,         stretching  of  the  calf  muscles,  PA 
Stride  sit  kneeling  raising,  AR 
Biparietal  movement 
Bitemporal  movement 

Coronal  suture  \nbration  and  occipital  suction  movement 
Frontal  vibration  and  double  upper  cervical  nerve  friction 
Nerve  frictions  round  the  side  of  the  sl\ul'l 
Half  lying  stomach  exercise,  PP   . . 
Temperature  chart,  case  of  typhoid  fever 
„       scarlet  fever. . 


11)11 
1(11 
Id.-, 
KMi 
KIT 
HI 
111 

ir_' 
Hi 

114 

11(1 

IKi 
117 
120 
121 
123 
12.S 
128 
130 
131 
135 
136 
140 
141 
141 
Kk) 
176 
176 
178 
189 
191 
193 
197 
198 

1 99 
214 
215 
216 
218 
218 
221 
222 
222 
227 
25.-. 
266 
269 


279 
280 
283 


LIST   OF    ILLUSTRATIONS 


FIG. 

99 
100 
101 
102 
103 
104 
l(t.5 
10(i 
107 
108 
109 
110 
111 

ir2 

113 
114 
11.", 
IKi 
117 
US 
llll 
120 
121 
122 
123 
124 
12.5 
12(i 
127 
12S 
129 
130 
131 
132 
133 
134 
135 
136 
137 
138 


Temperature  chart,  case  of  scarlet  fever  and  mumps    . . 

diphtheria 
erysipelas 

epidemic  cerebro-spinal  ineningitis 
rheumatic  fever  and  erytliema 
erythema  nodosum 
pneumonia    . . 
Illustration  of  case  of  chronic  pleurisy  and  spinal  ciirvatiu'e 

Temperature  chart  of  case  of  acute  peritonitis    . . 
Sphygmographic  tracing,  case  of  mitral  incompetence 


mitral  stenosis  and  incompetence 


Temperature  chart,  case  of  rheumatic  (?)  pericarditis,  &c. 
Spliygmographic  tracing,  case  of  rheumatic  (?)  pericarditis,  &c. 


Diagram  to  show  extent  of  a  case  of  lymphangitis 
Sphygmographic  tracing,  case  of  embolism  into  internal  capsule 


PAQK 
285 
286 
292 
294 
299 
301 
309 
315 
330 
332 
342 
360 
362 
362 
362 
362 
363 
363 
363 
364 
364 
365 
366 
367 
369 
370 
371 
374 
375 
376 
376 
377 
377 
378 
379 
383 
385 
400 
402 
403 


CONTENTS. 

PART    I. 

PAGE 

Preface      xiii. 

Chapter  I. — Introductory       ...         ...         ...         ...         ...         .-.         ...  1 

Chapter  II. — General  Classification  and  Definitions...         ...         ...  10 

Chapter  III. — Gymn.\stic  Positions             ...         ...         ...         ...         ••■  14 

Chapter  IV. — General  Physiologic.a.l  Effects  of  Active  and  Passive 

Movements           ...         ...         ...         ...         ...         ...         ...         ...  27 

Chapter  V. — Gymnastic  Movements  ..         ...         ...         ...         ...         ...  41 

Flexion  and  Extension  (including  Ringing  and  Falling)        ...         ...  45 

.\bduction  and  Adduction...         ...         ...         ...         ...         ...         ...  89 

Rotation  (Turning)   ...         ...         ...         ...         ...         ...         ...         ...  97 

Pronation  and  Supination...         ...         ...         ...         101 

Inversion  and  E version      ...         ...         ...          ...         ...         ...          ...  102 

Circumduction  or  Rolling    ...         ...         ...         ...         ...         ...         ...  103 

Traction          114 

(Arm-)  Carrying        117 

Drawing          ...         ...         ...         ...         ...         ...         ...         ...         ...  119 

Expansion      ...         ...         ...         ...         ...         ...         ...         124 

Lifting            131 

Shaking  and  Vibration       ...          ...         ...         ...         ...         ...         ...  133 

Friction          ...         ...         ...         ...         ...         ...         ...         ...         ...  133 

Hacking,  Clapping  and   Beating...         ...         ...          ...         197 

Stroking         '. 205 

Kneading         207 

Pressing          ...         ...         ...         ...         ...          ...         ...         ...         ..-  213 

Various    other    Movements    which    do    not   f.ill    under   any  of   the 

previous  headings        ...         ...         ...         ...         ...         ...         ...  214 

Special  Manipulations  of  Various  Regions  and  Organs        ...         ...  220 

Chapter  VI. — CoxcLrniNG  Rem.\rks  to  Part  1 240 

PART    II. 

Preface     ...         ...         ...         ...         ...  246 

Chapter  I. — Diaunostic  Exercises    ...         ...         ...         ...         ...         ...  247 

Chapter  II. — General  Principles  in  the  Application  of  the  Manu.al 

Treatment 249 


X.  CONTEXTS 

PAGE 

Chapter  III. — Specific  Infectious  Diseases         ...         ...         251 

*Typhoid  Fever          253 

*Whooping  Cough      ...         ...         ...         ...         ...         ...         ...         ...  259 

*JIensles  following  on  Whooping  Cough    ...         ...         ...         ...         ...  260 

♦Measles           263 

♦Scarlatina  Anginosa ...         ...         ...         ...         ...         ...         ...         ...  266 

♦.Scarlatina  .\nginosa ...         ...         ...         ...         ...         ...         ...         ...  269 

♦Scarlatina  Anginosa ...         ...         ...         ...         ...         ...         ...         ...  270 

♦Scarlatina  Suuplex    ...         ...         ...         ...         ...         ...         ...         ...  273 

♦Scarlatina  Anginosa  ...         ...         ...         ...         ...         ...         ...         ...  274 

♦Scarlatina  Gravior,  with  Middle  Ear  Disease      ...         ...  276 

♦Scarlatina  .^.nginosa,  followed  by  a  Chill  with  Spinal  Symptoms  and 

Epidemic  Parotitis  {'?)      ...         ...         ...         ...         ...         ...         ...  276 

♦Scarlatina  ."Vnginosa ...         ...         ...         ...         ...         ...         ...         ...  278 

♦Scarlatina  Anginosa ...         ...         ...  280 

♦Scarlatina  Anginosa,  followed  by  Epidemic  Parotitis    ...         ...         ...  282 

♦Scarlatina  Anginosa  with  Epidemic  Parotitis      ...         ...         ...         ...  284 

♦Scarlatina  Simplex,  followed  by  Epidemic  Parotitis      ...         ...         ...  286 

♦Scarlatina  Gravior    ...         ...         ...         ...         ...         ...         ...         ...  288 

♦Epidemic  Parotitis 289 

Diphtheria      291 

Erysipelas  Migrans  BuUosum         ...         ...         ...         ...  293 

Epidemic  Cerebro-spinal  Meningitis         ...         ...         ...  298 

♦Rheumatic  Fever  and  Erythema  ...         ...         ...         ...         ...         ...  300 

♦Erythema  Nodosum...         ...         ...         ...         ...  309 

Chapter  IV. — Diseases  of  the  Respie.\tory  Organs       ...         ...         ...  311 

Acute  Croupous  Pneumonia           ...         ..          ...         ...         ...         ...  311 

♦Acute  Bronchitis       ...         ...         ...         ...         ...         ...         ...         ...  316 

Acute  Pleurisy           ...         ...         ...         ...         ...         ...         ...         ...  318 

Chronic  Pleurisy        321 

♦Case  1      323 

♦Case  2     325 

♦Case  3     327 

♦Case  4 328 

Chapter   V.— Diseases  of  the  Digestive  Organs           ...         ...         ...  334 

Acute  Membranous  Tonsilitis       ...         ...         ...         ...         ...         ...  334 

Acute  Catarrhal  Appendicitis        ...         ...  335 

Case  1 336 

♦Case  2 339 

♦Acute  rapidly  extending  Peritonitis       ...         ...         ...         ...         ...  341 

.•Vcute  Gastrointestinal  Catarrh     ...         ...         ...         ...  345 

Acute  Intestinal  Catarrh 346 

Chronic   Appendicitis          ...         ...         ...  347 

*  The  cases  marked  witli  an  asterisk  were  not  included  in  the  original  thesis 
of  1901. 


CONTENTS 


Constipation 

Case  1     

Case  2 

*Chronic   Intestinal    Catarrh 
*Diarrhcea 
Chapter  VI. — Heart  Diseases 
Mitral   Incompetence 
Mitral  Stenosis  and  Incompetence 
*Mitral  Stenosis  and  Incompetence 
*Rheumatic  (?)  Pericaj-ditis,  Cardiac  Dilatation  and  Mitral  Disea: 

Chapter    VII. — Diseases    of  the    Blood.   Lymphatics    and    Dv 
Glands 
Chlorosis 
Lymphangitis 

Case  1      .' 

Case  2 

Case  3     

Case  4     ... 

♦Case  5     

♦Exophthalmic  Goitre 

Chapter  VIII. — Diseases  of  the  Nervous  System 
Embolism  into  the  Internal  Capsnle 
♦Infantile  Spastic  Diplegia    ... 
♦Diplegia  fi'om  Cerebral  Hiemorrhage 
♦Sequelie  of  Meningitis  (Syphilitic! 
Bulbar  Paralysis 

Disseminated  Cerebro-spinal  Sclerosis 
♦Spinal  Apoplexy  during  Secondary  Syiihilis 
Infantile  Paralysis    ... 
Case  1 

Case  2      

Facial  Paralysis  of  Peripheral  Origin 
Post-diphtheritic  Paralysis  ... 
Neuralgia  and  Neuritis 

Supraorbital  Neuralgia 
♦Sciatica   ... 
♦Sciatica   ... 
Mental  Overwork 
Sequelie  of  Influenza 

Case  1      

Case  2 

Chronic  Headache     ... 

Epileptic  Seizure  while  Bathing    ... 

*  The  cases  marked  with  an  asterisk  were  not  included  in  the  original 
of  1901. 


page 
349 
350 
351 
3.-)l 
3.53 
35.5 
359 
364 
368 
370 

380 
380 
382 
382 
384 
885 
386 
386 
387 

391 
397 
403 
407 
414 
420 
423 
433 
437 
438 
441 
444 
445 
447 
447 
448 
450 
451 
454 
454 
455 
456 
457 


CONTENTS 


Chai'TER  IX. — Diseases  of  the  Locomotor 
Clironic  Elieumatisiu 
Case  1 

♦Case  2     

Case  3,  Lumbago 
Case  4,  Lumbago 
♦Case  5,  Lumbago 
Sprain  of  the  Gastrocnemius   Muscle 
Chronic  Synovitis,  &c. 
Abscess  in  the  Antrum  of  Highmore 
Dislocation  of  the  right  Humerus 
♦Dislocation  of  the  left  Humerus  ... 

Chapter  X. — Diseases  of  the  GENiio-URiN.iRY  Organs 
♦Sudden  Incontinence  of  the  Bladder 
♦Menorrhagia  ... 

♦Threatening  Mammary  Abscess  ... 
♦Labour 

Appendix    ... 


PAGE 

461 
461 
461 
462 
463 
465 
466 
466 
467 
469 
470 
472 

474 

474 
474 
476 
476 

478 


*  The  eases  marked  with  au  asterisk  were  not  included  in  the  original   thesis 
of  1901. 


PREFACE. 

This  book  has  been  written  with  the  object  of  providing  the 
medical  profession  with  a  scientific  exposition  of  the  methods 
comprised  under  what  is  widely  known  as  "  Kellgren's  Manual 
Treatment."  It  is  founded  upon  the  thesis  which,  under  the 
same  title,  was  accepted  with  commendation  by  the  University 
of  Edinburgh  in  1901,  and  gained  for  me  the  degree  of  M.D.; 
but  the  original  thesis  has  undergone  considerable  expansion. 
Greater  experience,  more  extended  observation  and  a  wider  range 
of  reading  have  led  me  to  add  so  much  to  the  first  part  that  it 
has  in  effect  been  rewritten ;  and  in  the  second  part  I  have  in- 
cluded the.  details  of  many  cases  treated  in  the  course  of  my  prac- 
tice after  leaving  Edinburgh. 

Some  exceptional  difficulties  have  attended  the  compilation  of 
this  treatise.  For  the  first  time  has  been  attempted  a  systematic, 
detailed  description  of  Kellgren's  Manual  Treatment ;  and  the 
task,  onerous  in  itself,  has  been  complicated  by  the  fact  that  the 
physiological  groundwork  was  insufficiently  investigated,  experi- 
menters having  hitherto  conducted  but  few  researches  into  the 
phenomena  resulting  from  gymnastic  exercises.  In  addition,  I 
have  only  been  able  to  write  during  the  occasional  hours  I 
could  spare  from  my  practice,  the  continuance  of  which  being 
necessary  not  only  for  the  double  design  of  accumulating  fresh 
evidence  and  verifying  conclusions  already  drawn,  but  also  for 
the  purpose  of  widening  as  far  as  possible  in  every  direction 
the  range  of  that  practical  work  which  forms  the  basis  of  all 
sound  theory. 

The  present  volume,  although  dealing  with  all  the  chief 
features  of  the  subject  under  consideration,  makes  no  pretence 
to  exhaustiveness.  I  trust  it  will  prove  of  such  interest  to  the 
medical  profession  as  to  stimulate  further  enquiry,  and  I  look 
forward  to  the  time  when  many  of  the  hitherto  unsolved 
problems  connected  with  the  manual  treatment  will  cease  to 
baffle  our  understanding.     Above  all,  it  is  my  earnest  hope  that 


xiv.  PREFACE 

this  treatment  will  receive  the  acknowledgment  and  encourage- 
ment it  so  richly  deserves,  and  that  it  will  speedily  be  relegated 
to  its  proper  place  in  the  world  of  modern  theurapeutics. 

My  very  best  thanks  are  due  : 

To  Mr.  Henrik  Kellgren,  under  whom  I  have  studied  at 
intervals  from  1893  until  the  time  of  writing,  and  to  whom  I 
lie  under  obligations  of  gratitude  which  it  is  impossible  to  repay. 

To  Dr.  Harry  Kellgren,  for  most  useful  aid  in  many  direc- 
tions, including  the  classification  and  description  of  shakings, 
vibrations,  and  frictions. 

To  Professor  Starling,  for  valuable  advice  on  some  of  the 
points  connected  with  the  physiological  effects  of  the  various 
movements. 

To  Mr.  Allan  Broman,  for  many  kind  suggestions  and  for 
generous  assistance  in  the  revision  of  the  whole  of' my  work. 

To  my  wife,  Annjuta  Cyriax,  medical  student,  my  sister, 
Eva  Cyriax,  B.Sc,  and  Mr.  Svahnberg,  for  help  in  numerous 
ways  which  it  would  take  too  long  to  specify  minutely. 

Edgar    F.   Cyriax. 


London,   1903. 


PART  I. 

GYMNASTIC    MOVEMENTS. 


THE    ELEMENTS    OF    KELLGREN'S    MANUAL 
TREATMENT. 

CHAPTER  I. 

INTRODUCTORY. 

Although  medical  gymnastics  and  also  massage  in  some 
form  or  other  have  been  in  use  for  all  time  of  which  there  exists 
any  historical  record,  the  first  attempt  to  place  a  system  of  such 
movements  on  a  scientific  basis  was  made  by  the  Swede,  Pehr 
Henrik  Ling. 

Ling  was  born  in  Ljunga,  in  the  south  of  Sweden,  in  1776. 
He  matriculated  in  1793,  and  applied  himself  to  the  study  of 
divinity,  intending  to  follow  in  the  footsteps  of  his  father ;  in 
1797  he  took  his  degree.  But  his  restless  spirit  rebelled  against 
a  sedentary  life ;  Ling  wished  to  travel,  and  accordingly  left  his 
native  country.  First  he  went  to  Copenhagen,  where  he  figured 
in  various  capacities,  amongst  others  as  a  teacher  of  modern 
languages.  Then  he  left  Copenhagen,  but  of  the  ensuing  few 
years  of  his  life  information  is  meagre  and  indefinite.  It  is 
certain  that  he  visited  Germany  and  France ;  and  also  it  is 
probable  that  during  the  course  of  his  wanderings  he  spent  some 
time  in  England  ;  but  his  career  cannot  be  traced  again  with 
accuracy  until  1804.  In  that  year  Ling  was  back  in  Sweden, 
and  in  the  town  of  Lund  was  established  as  an  instructor  in  the 
arts  of  fencing  and  gymnastics.  While  on  the  Continent  he  had 
been  compelled  in  consequence  of  pecuniary  difficulties  to  undergo 
many  hardships  and  privations,  resulting  in  serious  damage  to  his 
health ;  at  the  time  already  referred  to  his  constitution  was  much 
impaired,  and  he  was  a  constant  martyr  to  rheumatism.  Bodily 
1 


2        ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

ailments  did  not,  however,  keep  him  from  pursuing  an  active 
life,  and  his  reputation  as  a  master  of  fencing  and  gymnastics 
developed  into  considerahle  fame. 

The  movements  and  exercise  necessitated  by  his  daily  work 
soon  proved  of  great  benefit  to  his  physical  condition,  and  shortly 
after  his  appointment  in  1805  as  fencing  master  to  the  University 
of  Lund,  Ling  found  that  his  rheumatism  had  disappeared,  and 
that  he  had  regained  his  former  strength  and  vigour.  These 
facts  turned  his  thoughts  in  a  new  direction.  What  had  been  of 
benefit  to  himself  might  also  be  of  benefit  to  others,  and  he  came 
to  the  conclusion  that  it  ought  to  be  possible  to  devise  various 
movements  with  different  physiological  effects  for  the  treatment 
of  various  ailments.  He  likewise  argued  that  a  further  series  of 
movements  could  be  contrived  which  would  tend  not  only  to 
keep  healthy  persons  in  that  condition,  but  also  to  strengthen 
them  by  developing  their  bodies  equally  in  all  directions. 

The  question  now  arose  :  how  could  these  theories  be  turned 
to  practical  account  ?  Ling  saw  that  it  was  impossible  to  work 
out  a  rational  system  of  gymnastics  without  previous  knowledge 
both  of  the  structure  of  the  human  organism  and  of  its  complex 
functions  ;  he  brought  the  matter  to  the  notice  of  the  Senatus 
of  the  University,  and  made  formal  application  for  permission 
to  study  anatomy  and  physiology.  This  was  readily  granted,  and 
in  1806  he  began  to  attend  the  dissecting-rooms  and  hear  lectures. 
Not  only  did  he  make  himself  a  thorough  master  of  what  at  that 
time  could  be  learnt  in  the  departments  of  medical  science  above 
specified,  but  in  the  course  of  years  he  went  through  nearly 
the  entire  curriculum  required  of  candidates  for  degrees  in 
medicine  and  surgery,  without,  however,  actually  taking  any 
qualification. 

In  the  light  of  the  extensive  knowledge  thus  obtained,  Ling, 
by  adopting,  adapting,  and  modifying  some  of  the  movements 
he  had  learnt  on  the  Continent,  and  by  devising  many  other  new 
ones,  at  last  produced  a  practically  new  system  of  gymnastics  which 
is  called  after  him.     This  system  is  divided  into  four  branches  : — 

(1)  Pedagogical  (educational),  in  which  the  individual  learns 
to  place  his  body  under  his  own  control. 

(2)  Medical,  in  which  is  learnt  the  alleviation  or  cure  of 
diseased  conditions. 

(3)  Military  (antagonistics),  in  which  the  individual  learns  to 


INTRODUCTORY  3 

bring  an  external  object  {e.g.,  a  weapon)  under  his  own  will 
and  control. 

(4)  iEsthetic,  in  which  the  individual  learns  by  movements 
(gestures)  to  express  his  inner  thoughts  and  feelings. 

The  system  very  soon  awoke  the  public  interest,  and  Ling 
tried  to  induce  the  Swedish  Government  to  assist  him  in  founding 
an  institution  for  the  practice,  study,  and  teaching  of  the  new 
methods.  His  efforts,  for  some  time  in  vain,  were  at  length 
crowned  with  success,  and  in  1813  the  Eoyal  Gymnastic  Central 
Institute,'  subsidised  by  State,  was  opened  in  Stockholm,  and 
lie  was  appointed  its  first  Principal. 

The  medical  part  of  his  system  did  not  at  first  meet  with 
the  approval  of  members  of  the  orthodox  medical  profession, 
who,  in  fact,  did  all  they  could  to  prevent  its  gaining  ground. 
This  is  scarcely  to  be  wondered  at,  as  the  fundamental  principle 
on  which  it  was  founded  {i.e.,  the  beneficial  effect  of  movement) 
was  directly  opposed  to  the  doctrines  which  had  ruled  for  so 
many  years.  Ling  and  his  pupils,  however,  in  the  face  of  great 
discouragements,  persisted  in  their  efforts  to  get  the  value  of 
their  methods  recognised  ;  they  kept  on  demonstrating  practically 
the  results  which  could  be  obtained  thereby,  and  at  length,  after 
many  weary  years  of  work  and  waiting,  they  achieved  their 
purpose,  as  is  evident  from  the  fact  that  in  1831  Ling  was  elected 
by  the  Swedish  General  Medical  Association  to  be  a  member 
of  their  body. 

Ling  died  in  1839,  and  according  to  his  own  words,  uttered 
shortly  before  his  death,  left  behind  him  only  two  men  who  really 
understood  his  system  and  were  capable  of  furthering  its  progress.^ 
These  were  Lars  Gabriel  granting,  the  greatest  of  all  bis  pupils, 
and   Karl   Augustus   Georgii.     The   former   already  installed  at 

'  I  shall  iu  the  ensuing  pages  use  the  abbreviation  G.C.I,  to  denote  this 
Institute. 

-  The  following  is  a  list  of  the  chief  biographical  papers  on  Ling : — Frost, 
"  Minnesord  ufver  ...  P.  Henrik  Ling,"  &c.,  May  9,  1839,  translated  into  German 
in  1861  by  Rothstein,  under  the  title  of  '•  Gedenkrede  auf  Pehr  Heurik  Ling." 
Atterbom,  "  lutriidestal  i  Svenska  Akadomien,"  1840.  Werlauff,  "  Bidrag  till  P.  H. 
Ling's  Biografi,"  in  Freij,  1S48,  pages  92-105.  Nyblfeus,  "  Ling  och  Gymnastiken," 
1853.  Georgii,  "  A  Biographical  Sketch  of  the  Swedish  Poet  and  Gymnasiarch, 
Pehr  Henrik  Ling,"  1854.  Beskow,  "Minnesteckning  P.  H.  Ling,"  1866.  Nybljeus, 
"  Minnestal  (ifver  Pehr  Henrik  Ling,"  1870.  J.  L.  (.letta  Liedbeck),  "  Pehr  Henrik 
Ling,"  in  Tidskrift  i  Gymnastik  (the  biannual  journal  of  the  G.C.I.),  vol.  iii. 
part  10,  1893,  pages  870-891.  Torngren,  "Minnestal  ofver  Pehr  Henrik  Ling  den 
15  Nov.,  1896,"  in  Tidskrift  i  Gymnastik,  vol.  iv.,  part  7,  1896,  pages  413-432. 


4       ELEMENTS   OF   KELLGREN'S   MANUAL    TREATMENT 

the  G.C.I,  as  one  of  the  head  instructors,  stepped  into  the 
chair  rendered  vacant  by  Ling's  death ;  Georgii  became  sub- 
director,  which  post  he  held  until  1849.' 

About  this  time  two  new  men  came  into  prominence.  Major 
Eothstein  and  Dr.  Neumann,  both  Germans,  who  went  to  Stock- 
holm in  order  to  study  Ling's  system.  Later  on  Eothstein 
published  the  only  systematic  comprehensive  work  on  Ling's 
system  that  exists  (although  the  section  on  medical  gymnastics  is 
incomplete,  and  the  one  to  which  least  space  is  devoted).  It 
is  entitled  "  Die  Gymnastik  nach  dem  System  des  Schwedischen 
Gymnasiarchen  P.  H.  Ling."  Neumann,  a  most  careful  observer, 
published  various  treatises — "iDie  Heilgymnastik,"  "  Lehrbuch  der 
Leibesiibungen,"  &c.,  which,  although  excellent  in  many  parts, 
are  characterised  by  a  decided  tendency  to  exaggeration  and 
hyperoptimistic  views.  To  Eothstein  and  Neumann  belongs  the 
credit  of  having  introduced  Ling's  system  into  Germany. 

When  Brantiug  resigned  in  1862,  Georgii  was  invited  to 
succeed  him,  but  declined,  chiefly  because  he  was  attempting 
to  introduce  Ling's  system  into  England,  and  did  not  wish  to 
leave  the  field  of  his  labours. 

Both  Branting  and  Georgii  were  assisted  in  their  work  by 
Hjalmar  Ling^  (son  of  P.  H.  Ling),  who  was  as  energetic  as 
either  of  the  others  in  developing  his  father's  system.  He  was 
professor  of  anatomy  at  the  G.C.I.,  from  18-51-1864,  when  he 
was  appointed  professor  of  pedagogical  gymnastics,  a  position 
which  he  retained  until  1882.  Together  with  Thure  Brandt,'  who 
specialised  in  the  gymnastic  treatment  of  female  diseases,  the 
afore-mentioned  Swedes  must  be  regarded  as  the  pioneers  of 
the  system,  and  as  those  who  did  most  for  it.  No  one  of  them 
I  possessed  the  orthodox  medical  qualification ;  but  each  had 
minutely  studied  anatomy,  physiology,  pathology  and  the  nec- 
essary branches  of  science  without  knowledge  of  which  they 
would,  of  course,  have  been  helpless  and  unable  to  make  any 
progress. 

'  Short  biographical  sketches  of  Brautiug  and  Georgii  have  been  published  by 
Hartelius  in  Tidskrift  i  Gymnastik,  i.e.,  Hartelius's  "  Lefnadsteolsning  ofver  L.  G. 
Branting,"  part  15,  1S81,  page  931,  &c.,  and  "  Lefnadsteckning  ofver  Carl  August 
Georgii,"  part  16,  1881,  page  989. 

^  No  biographical  sketch  o£  Hjalmar  Ijing  has  been  published  in  Tidskrift  i 
Gymnastik. 

"  A  biographical  sketch  of  Thure  Brandt  has  been  published  by  Wide  in  Tidskrift 
i  Gymnastik  for  1895,  part  ii. ,  p.  247. 


INTRODUCTORY  S 

Although  the  results  had  been  recognised  by  the  members  of 
the  medical  profession  in  Sweden,  but  few  of  the  latter  studied 
the  system  at  all  carefully  or  with  a  view  to  actually  practising  it. 
One  of  those  who  did  so  was  T.  J.  Hartelius,  M.D./  who  was 
appointed  professor  of  the  medical  department  of  the  G.C.I,  in 
1864.  He  retained  his  post  there  until  1887,  when  he  was  suc- 
ceeded by  Kobert  Murray,  M.D.,  who  holds  it  to  the  present  day. 

In  order  for  a  non-medically  qualified  man  to  graduate  as  a 
practitioner  of  Ling's  medical  gymnastics,  the  complete  course  at 
the  G.C.I,  must  be  taken;  this  lasts  three  years.  Candidates 
have  to  acquire  a  theoretical  and  practical  knowledge  of  peda- 
gogical, military  and  medical  gymnastics,  together  with  anatomy, 
physiology,  pathology  and  symptomatology.  In  the  case  of 
qualified  medical  men  a  course  of  one  year  (such  as  I  attended 
1898-1899)  is  deemed  sufficient.  It  consists  of  practical  and 
theoretical  instruction  in  pedagogical  and  medical  gymnastics,  the 
military  portion  not  being  considered  essential.  A  knowledge  of 
the  pedagogical  portion  is  regarded  as  of  the  greatest  importance, 
as  from  it  the  medical  branch  is  and  has  been  to  a  great 
extent  evolved  ;  some  of  the  exercises  are  common  to  both, 
and  there  is  no  sharp  line  of  demarcation  between  the  two.  Also 
pedagogical  gymnastics  are  to  be  regarded  as  forming  a  hygienic 
and  a  prophylactic  system  ;  by  developing  the  entire  body  they 
promote  health  and  strength,  and  thus  tend  to  ward  off  disease  ; 
or  if  the  latter  has  set  in  they  enable  the  body  to  recover  from 
disease  more  quickly  and  thoroughly  than  could  otherwise  have 
been  the  case. 

At  the  end  of  the  curriculum,  after  duly  passing  all  examina- 
tions (which  are  conducted  only  in  the  Swedish  language),  the 
candidate  receives  the  title  of  Gymnastic  Director,  which  legally 
entitles  him  to  practice  as  a  medical  gymnast,  and  places  him 
under  the  jurisdiction  of  the  General  Medical  Council. 

In  spite  of  the  fact  that  there  is  such  a  special  course  of  short 
duration  for  medical  men,  very  few  avail  themselves  of  it,  and 
continual  complaints  have  been  raised  that  doctors  and  others 
coming  from  various  parts  of  the  world  to  Stockholm  pay  casual 
visits  to  the  Institute,  varying  from  a  few  minutes  to  a  few  weeks, 
and  then  return  home  posing  as  authorities  on  Ling's  medical 

'  A  biographical  slcetch  of  Hartelius  has  been  published  by  Levin  in  Tidskri/t 
Gymnastik,  1896,  part  ii.  p.  449. 


6       ELEMENTS   OF   KELLGREN'S   MANUAL    TREATMENT 

gymnastics.  Hjalmar  Liug,  in  his  preface  to  Branting's  post- 
humous works,  issued  under  the  title  of  "  Efterlemnade  Skrifter  " 
in  3882,  says  (pp.  xlvi.  and  xlvii.,  translated),  "Frenchmen, 
Belgians,  Englishmen,  Italians  and  Russians,  have  in  the  course 
of  years  now  and  then  sent  here  so-called  authorities,  who  have 
stayed  in  Stockholm  a  few  days,  partaken  of  ceremonial  dinners, 
looked  on  at  the  gymnastics  without  taking  any  practical  part  in 
them,  and  who  understood  nothing,  neither  the  language  nor  the 
subject."  Such  complaints  are  still  rife  and  Professor  Torngren 
(now  head  of  the  Institute)  and  Professor  Murray  have  frequently 
been  heard  to  deplore  the  fact  that  such  flying  visits  are  the  rule 
and  not  the  exception. 

It  is  a  matter  of  great  regret  that  neither  P.  H.  Ling,  Branting, 
Georgii,  nor  Hj.  Ling  ever  issued  a  comprehensive  work  on  the 
subject  of  Ling's  medical  gymnastics.^  Being  absorbed  in 
obtaining  practical  results  they  had  but  little  time  to  devote  to 
writing,  which  they  left  to  others.  P.  H.  Lmg-  says:  "I  have 
gone  my  own  way  and  have  not  written,"  a  statement  which  as 
far  as  medical  gymnastics  are  concerned  might  with  equal  truth 
have  come  from  his  pupils  mentioned  above. 

In  consequence,  any  one  who  wishes  to  enrich  the  literature 
of  the  subject  is  hampered  at  the  outset  by  the  absence  of  any 
standard  comprehensive  work  by  a  real  authority.  And  as  a 
result  of  the  casual  hurried  visits  mentioned  above,  the  vast 
majority  of  books  and  articles  written  on  the  subject  by  so-called 
"  authorities "  show  a  deplorable  ignorance  of  even  the  very 
elements  of  Ling's  system.  And  in  the  course  of  time  new 
authors,  unable  to  carry  oat  researches  on  their  own  account, 
have  been  compelled  to  fall  back  upon  the  productions  of  persons 
no  better  informed  than  themselves.  In  this  way  there  has 
accumulated   an   extensive   literature   about    Ling's   system,   but 

'  The  following  is  a  list  of  their  works  on  medical  gymnastics : — P.  H.  Ling, 
"  Gymnastikens  Allmanna  Grunder,"  1834  (18iO),  reprinted  with  additions  in  186G 
(a  small  portion  only).  This  work  was  translated  by  IMassmann  and  istued  under 
the  title  of  "  P.  H.  Ling's  Sehriften  iiber  Leibesiibungen,"  in  1847.  Branting, 
"  Efterlemnade  Skrifter,"  1882  (a  portion  only).  Georgii,  "  Kinesithorapie  ou 
Traitement  des  Slaladies  par  le  Mouvemeut,"  1847  ;  "  A  few  words  on  Kinesipathy, 
or  Swedish  Medical  Gymnastics,"  1850  ;  "  The  Movement  Cure,"  1853.  Hj.  Ling, 
"De  Fbrsta  Begreppen  af  Rorelselaran,"  18C6  (portion  only) ;  "  Forkortad  ()fversigt 
af  AUman  Eorelseliira,"  1880  (portion  only);  preface  to  Branting's  "Efterjemnade 
Skrifter,"  1882  (portion  only). 

-  "  Gymnastikens  Allmanna  Grunder,"  1884  (1840),  p.  1. 


INTRODUCTORY  7 

only  very  few  works  can  be  selected  from  it  that  have  real 
value.  It  would  appear  that  nowadays  the  mere  production  of  a 
book  labelled  "  Die  Schwedische  Heilgymnastik,"  or  bearing  some 
similar  title,  is  regarded  as  proof  positive  of  the  author's  practical 
and  theoretical  ability. 

Of  late  years  much  has  been  done  to  degrade  the  profession  of 
medical  gymnast,  and  the  system  has  suffered  in  consequence. 
Nowadays  all  gymnasts  in  Sw-eden  have  to  act  under  the  super- 
vision of  a  medical  man,  which  would  certainly  be  an  advantage 
for  the  former  were  his  method  of  treatment  understood  by  the 
latter.  Unfortunatel}',  however,  the  majority  of  medical  men 
know  next  to  nothing  about  it.  Instances  continually  recur  of 
patients  who,  while  undergoing  a  gymnastic  cure,  are  ordered  to 
stop  it  every  nd>w  and  then  because  they  complain  of  not  feeling 
quite  as  well  as  they  might  be ;  often  their  medical  man  orders 
them  rest  in  bed  and  some  medicinal  remedy  until  they  feel 
better.'  This  certainly  implies  that  the  members  of  the  medical 
profession  in  Sweden  regard  gymnastics  as  a  somewhat  dangerous 
method  of  cure.  At  any  rate  they  nowadays  trust  only  the 
simplest  cases  to  the  gymnast,  and  they  are  more  and  more 
disposed  to  limit  the  field  of  diseases  in  which  gymnastic  treat- 
ment might  be  used  with  benefit.  All  this  has  resulted  in  what 
may  be  described  as  "  oppression  of  the  gymnastic  profession." 

Ling's  system  has  during  the  last  few  years  undergone  con- 
siderable modification  ;  this  is  mainly  due  to  the  efforts  of  Anders 
Wide,  M.D.,  of  Stockholm.  The  latter  has  embodied  his  ideas  in 
a  book  entitled  "  Handbok  i  Medicinsk  Gymnastik,"  published  in 
1895-1896,  translated  into  German  in  1897,  into  French  in  1898. 
and  into  English,  under  the  name  of  "  Handbook  of  Medical 
Gymnastics,"  in  1899  ;  the  Swedish  edition  was  re-issued  in  1902 
as  "Handbok  i  Medicinsk  och  Ortopedisk  Gymnastik,"  and 
translated  in  the  next  year  into  English  as  "Handbook  of 
Medical  and  Orthopsedic  Gymnastics."  Until  the  publication  of 
his  works  the  only  systematic  treatise  that  had  been  issued  in 
Swedish  was  Hartelius'  "Larobok  i  Sjukgymnastik,"  1870, 
reprinted  1883  and  1892.  In  consequence,  Wide's  publications 
have  been  accepted  as  standard  works,   especially  by  Swedish 

'  This,  as  can  readily  be  understood,  is  a  great  grievance  for  the  gymnast.  Cf. 
Hartelius,  "  Den  Pedagogiska  och  Medicinska  Gymnastiken,"  in  Tidskrift  i 
Gymnastik,  vol.  1.,  part  7,  1887,  p.  313,  &c. 


8       ELEMENTS   OF   KELLGREN'S   MANUAL    TREATMENT 

medical  men,  who,  as  I  have  said  before,  in  the  main  know  hardly 
anything  about  tliis  branch  of  therapeutics ;  they  have  also  been 
thus  accepted  by  many  medical  men  on  the  Continent '  who  have 
taken  up  massage  and  gymnastics  as  a  speciality.  It  shows, 
however,  how  little  his  supporters  know  about  Ling's  gymnastics 
when  I  assert  as  beyond  doubt  that  the  first  part  of  his  handbook 
(consisting  of  about  150  pages),  containing  the  descriptions  of  the 
various  movements,  teems  with  misstatements  and  technical 
errors.  Besides  this  it  is  obvious  to  a  careful  student  that  the 
modus  operandi  of  many  of  the  exercises  is  described  so  faultily 
that  it  is  impossible  to  gather  the  precise  mode  of  execution,  and 
the  effects  that  these  exercises  are  meant  to  produce,  both 
from  a  ph3'siological  and  anatomical  point  of  view,  are  in  the 
majority  of  cases  entirely  omitted.  Most  emphatically  a  hand- 
book based  on  such  a  lack  of  sound  fundamental  principles 
should  never  have  been  written.  The  results  of  the  cases 
treated  by  Wide  are  seldom  in  any  way  remarkable,  and  in 
some  cases  they  show  a  distinct  retrogression  compared  with  the 
results  obtained  from  Ling's  system  in  past  years.  In  fact, 
gymnastics  given  formerly  according  to  the  latter's  methods 
are  becoming  modified  to  suit  those  of  Wide,  and  this  is  a 
change  for  the  worse,  one  which  I  sincerely  hope  may  soon  be 
effectively  checked. 

Henrik  Kellgren,  born  in  1837,  entered  the  G.C.I,  in  18(53, 
and  v/orked  there  under  Hartelius  and  Hj.  Ling  until  1865, 
when  he  graduated  as  gymnastic  director.  Soon  after  he  had 
begun  to  practice  as  medical  gymnast  he  improved  many  of 
the  manipulations  already  existing  in  Ling's  system,  and  added 
some  that  were  new  (without,  however,  attempting  to  publish 
anything  concerning  the  same).  As  an  example  of  the  new 
manipulations  may  be  quoted  nerve  frictions  and  vibrations,  by 
means  of  which  he  was  able  to  treat  vcith  remarkable  success 
diseases  of  the  central  nervous  system,  kc,  and  which,  in  his 
hands,  formed  a  powerful  weapon  to  combat  acute  specific 
infectious  diseases. 

It  would  appear,  therefore,  that  at  the  present  time  there  are 
two  distinct  branches  of  Ling's  system.     The  one,  as  expounded 

'  Jlany  criticisms  on  Wide's  German  translation  have  been  reprinted,  under  the 
title  of  "  Referate  iiber  Handbuch  der  Medicinisehen  Gymnastik  von  Dr.  Med. 
A.  Wide,"  by  0.  Wide,  in  Tidxkrift  i  Chjmnastik,  1898,  part  2,  pp.  712-734. 


INTRODUCTORY  g 

in  Wide's  handbook,  is  a  distinct  retrogression  and  does  not 
compare  favourably,  either  in  method  or  results,  with  Ling's 
system  as  practised  by  Branting,  Georgii  and  Hartelius.  The 
other,  as  practised  by  Henrik  Kellgren,  marks  an  equally  distinct 
progress,  both  in  the  variety  and  the  technique  of  execution  of 
the  movements,  and  also  in  the  application  of  the  treatment  to 
many  fresh  cases,  hitherto  untouched  by  the  hand  of  the 
gymnast.  It  is  the  latter  branch,  to  which  the  name  of 
Kellgren's  Manual  Treatment  has  been  given,  that  I  intend  to 
interpret  in  this  work. 

Some  of  the  changes  made  by  Kellgren  are  often  apparently 
slight,  and  an  inexperienced  person  might  either  fail  to  detect 
them,  or  consider  them  too  trivial  to  be  worth  regarding.  With 
respect  to  this  treatment,  however,  more  so  than  in  the  case 
of  any  other,  such  apparently  slight  improvements  often  make 
a  very  great  difference  in  actual  practice,  and  heighten  enor- 
mously the  beneficial  effect  aimed  at. 

The  medical  profession  all  over  the  world  has  until  now 
almost  completely  ignored  Kellgren's  treatment,  and  thus  there 
are  hardly  any  essays  from  medical  men  on  the  subject.  The 
only  attempt  to  describe  any  of  Henrik  Kellgren's  exercises  and 
manipulations  are  to  be  found  in  the  writings  of  his  brother, 
Arvid  Kellgren,^  for  many  years  a  pupil  under  him,  a  graduate  of 
the  G.C.I,  and  M.D.  of  Edinburgh.  Apart  from  these  a  few 
casual  notes  by  other  authors  have  appeared  from  time  to  time 
in  stray  medical  periodicals,  but  that  is  all ;  in  short,  the 
literature  on  Kellgren's  treatment  is  practically  iiil. 


'  These  are  "  Vortriige  iiber  Massage,"  consisting  of  a  course  of  sixteen  demon- 
strations given  at  Pola  at  the  request  of  the  surgeons  of  the  Imperial  and  Royal 
Hungarian  Navy  in  1888-1889,  reproduced  in  "  Statischer  Sanitiitsbericht  iiber  die 
Ivaiserliche  uud  Konigliche  Kriegsmarine  fUr  das  Jahr  1888,"  and  "  Technic  of 
Ling's  System  of  Manual  Treatment,"  the  first  half  of  which  is  practically  the  same 
as  the  foregoing,  which  was  accepted  as  the  author's  thesis  for  the  degree  of  M.D. 
at  Edinburgh  in  1890.  His  latter  work  has  been  translated  into  French,  Italian, 
and  with  some  few  alterations  and  additions,  into  German. 


CHAPTER  IT. 

GENERAL    CLASSIFICATION    AND    DEFINITIONS. 

As  Kellgren's  methods  are  based  upon  Ling's,  I  shall,  whenever 
possible,  follow  the  example  of  the  best  textbooks  ^  on  Ling's 
system  regarding  classification,  arrangement,  Ac,  of  the  various 
positions,  exercises  and  manipulations. 

The  Swedish  term  "  Sjukgymnastik,"  which  may  be  trans- 
lated as  "  medical  gymnastics,"  has  at  various  times  been 
replaced  by  synonyms,  such  as  "  Rorelsekuren  "  (i.e.,  movement 
cure),  Heilorganik  (Neumann-)  "  Kinesitherapie,"  "  Kinesipathy  " 
(Georgii ')  and  others  too  numerous  to  mention. 

By  a  gymnastic  position  is  meant  the  posture  which  must  be 
correctly  assumed  before  a  gymnastic  movement  either  of  the 
active  or  passive  kind  can  be  executed,  and  which  must  be  strictly 
maintained  throughout  the  performance  of  such  movement  (with 
the  exception,  of  course,  of  that  part  of  the  body  which  is 
actively  brought  into  play  thereby).  This  rule  is  only  relaxed  in 
certain  cases  of  passive  movements  (see  Chapter  VI.). 

To  define  a  "  gymnastic  movement"  is  not  easy,  because  the 
term  is  applied  to  everything  from  the  most  powerful  active 
exercise  to  the  most  gently  and  lightly-applied  pj^ssive  manipula- 
tions. Its  various  significations  will  best  be  gathered  from  the 
following  classification  and  descriptions. 

Gymnastic  movements  are  divided  into  : — 
I. — Active. 
II. — Passive. 

I. — Active   Movements   are   such   as   are  performed  by  an 

'  The  only  two  textbooks  of  any  real  value  are  as  follows:  Neumann,  "Die 
Heilgymuastik,"  1852;  Hartelius,  "  Liirobok  i  Sjukgymnastik,"  first  edition  1870, 
second  edition  1883,  third  edition  1892. 

-  "Das  Jluskelleben  des  Menschen  in  Beziehung  auf  Heilgymnastik  und 
Turnen,"  1855,  j).  iii. 

'■'  "  Kinesitherapie  ou  Traitemeut  des  Maladies  par  le  Mouvement,"  1847.  "A 
Pew  Words  on  Kinesipathy,  or  Swedish  Medical  Gymnastics,"  1850. 


GENERAL  CLASSIFICATION  AND  DEFINITIONS  ii 

individual  through  his  own  volition,  and  by  means  of  his  own 
effort. 

In  order  to  accomplish  any  active  movement  definitely  and 
exactly  it  is  necessary  to  determine  clearly  the  following  con- 
ditions :  (1)  a  point  of  departure,  i.e.,  a  commencing  position; 
(2)  a  certain  number  of  intermediate  positions,  which  could 
theoretically  be  extended  to  infinity  ;  (3)  a  point  of  termination, 
i.e.,  a  final  position ;  (4)  the  velocity  and  rhythm  of  the 
movement. 

Active  movements  are  of  two  kinds  : — 

(1)  Without  resistance,  called  purely  active  or  unduplicated. 
These  are  further  divided  into  (a)  free  ;  (b)  bound. 

(2)  With  resistance,  called  duplicate.  These  are  further 
divided  into  (a)  concentric  ;  (b)  excentric. 

Purely  active  movements  are  those  in  the  course  of  which 
no  external  resistance  is  offered  to  the  patient's  efforts.  With 
the  "  bound  "  variety,  steadiness  and  isolation  are  secured  by 
means  of  fixation  or  support  either  from  apparatus  or  from 
external  assistance  applied  by  another  person;  with  the  "free" 
variety  no  such  means  are  employed. 

Duplicate  movements  are  those  in  the  course  of  which 
another  individual,  henceforth  to  be  called  the  assistant, 
resists  the  efforts  of  the  patient,  or  vice  versa.  The  resistance 
or  force  used  by  the  assistant  is  modified  according  to  each 
patient,  his  daily  variation,  and  the  nature  of  the  malady 
under  treatment,  so  that  the  maximum  effect  desirable  be 
obtained. 

In  a  duplicate  concentric  movement  the  assistant  resists 
while  the  patient  causes  his  own  contracting  muscles  to  shorten. 

In  a  duplicate  excentric  movement  the  patient  resists,  while 
the  assistant  causes  the  former's  "contracting"'  muscles  to 
become  longer. 

The  terms  "  duplicate  concentric  "  and  "  duplicate  excentric  " 
were  first  introduced  into  German  by  Neumann,"  and  have  since 
been  adopted  by  the  Ling  school,  who  speak  of  either  "  dupli- 
cerade  "  or  "  dubbel  "  exercises.     The  older  terms  were    "  half- 


'  It  seems  a  contradiction  to  speak  about  contracting  muscles  becoming  longer, 
but  the  terms  are  those  used  in  physiology. 

-  See  "  Zav  (Schwedisohen)  Heilgymnastik  "  in  Gasper's  Wochenschrift,  1849; 
"  Heilgymnastisohe  Pragmente,"  ibid.,  1850  ;   "  Die  Heilgymnastik,"  1852,  pp.15,  &c. 


12     ELEMENTS   OF  KELLGREK'S   MANUAL    TREATMENT 

aktiv  "  and  "  half-passiv  "  (c/.  Kothstein/ Eulenburg,-  <i'c.),  and 
were  distinctly  misleading,  as  they  gave  the  impression  that 
the  exercises  so  named  involved  less  expenditure  of  energy  than 
purely  active  ones.  Georgii"  used  the  expression  "specific 
active,"  Branting^  used  the  adjectives  "  tilltagande"  and  "  af- 
tagande,"  words  which,  literally  translated,  mean  increasing  and 
decreasing.  Another  term  used  by  the  Ling  school  is  "Mot- 
stiuidsrorelser,"  i.e.,  resistance  (also  called  resisted)  exercises 
(German  "  Widerstandsiibungen"). 

In  rare  cases  duplicate  movements  are  given  so  that  the 
assistant  offers  just  so  much  resistance  as  the  patient  is  unable 
to  overcome,  but  not  so  much  as  to  overpower  the  patient's 
efforts;  i.e.,  there  is  equilibrium  of  the  opposing  forces,  and  no 
movement  at  any  joint  actually  takes  place,  although  the  muscles 
called  into  action  may  exert  considerable  strength. 

During  the  performance  of  a  duplicate  movement  according 
to  Kellgren's  method,  an  additional  stimulatory  effect  is  obtained 
by  means  of  the  so-called  "  traction,"  as  follows  :  the  assistant, 
when  possible,  always  elongates  the  part  he  desires  to  affect  by 
stretching  its  distal  free  end  away  from  its  proximal  fixed  one, 
maintaining  this  condition  throughout  the  movement. 

It  has  been  stated  that  both  Branting  and  Hj.  Ling  used 
this  traction  when  giving  resisted  exercises.  The  obvious  re- 
joinder is  that  none  of  their  writings  even  so  much  as  mention 
it ;  nor  is  it  even  referred  to  in  the  works  of  Neumann, 
Eulenburg,  Georgii,  Both,  Rothstein,  or  Hartelius.  Most  cer- 
tainly it  was  not  in  use  and  not  advocated  at  the  G.C.I,  when 
I  was  a  student  there  in  1898-1899. 

Henrik  Kellgren  considers  that  the  application  of  traction  is 
a  very  important  factor,  a  point  which  can  easily  be  verified  by 
executing  the  same  exercise  both  with  and  without  it.  The 
difference  will  in  most  cases  manifest  itself  in  a  very  striking 
manner. 

'  "Die  GjTimastik  nach  dem  System  de.-s  Schwedischeu  Gymnasiarchen,  P.  H. 
Ling,"  1847,  vol.  i.,  pp.  14,  &c. 

=  Eulenburg  discusses  the  question  as  to  choice  of  terms  in  "  Die  Liugsche  oder 
Schwedische  Heilgymnastik  in  Ihrem  Werthe  von  Rationell-medicinisohen  Stand- 
punkte,"  in  Gbschen's  Deutsche  Klinik,  1852,  p.  338;  and  in  "  Uber  Wesen  und 
Ziel  der  Padagogisohen  Gymnastik  und  iiber  deren  Verhaltniss  zur  Schwedischeu 
Heilgymnastik,"  &c.,  ihld.,  1857,  p.  271. 

=  "  Kin^sith^rapie,"  1847,  p.  31 ;  "  The  Movement  Cure,"  1853,  p.  8. 

'  Brauting's  "  Efterlemuade  Skrifter,"  1882,  p.  8. 


GENERAL   CLASSIFICATION  AND  DEFINITIONS  13 

As  an  extra  group  may  be  specified  active  movements  with 
assistance.  To  this  variety  belong  such  cases  as  those  in  which 
a  patient  is  unable  to  achieve  a  movement  unaided  (in  conse- 
quence of  muscular  contracture,  partial  paralysis,  adhesions,  &c.), 
but  may  yet  be  enabled  to  perform  it  by  means  of  a  certain 
amount  of  help  (reduced  to  the  minimum). 

II. — Passive  Movements  are  such  as  are  applied  by  the 
assistant  to  the  patient  without  the  latter  offering  any  resistance 
or  assistance.^     There  are  two  main  classes  : — 

(1)  A  joint  or  joints  are  moved,  i.e.,  the  corresponding  active 
movements  are  imitated. 

(2)  No  joint  is  moved.  This  class  comprises  such  manipu- 
lations as  "  hacking  "  and  "  vibration." 


'  Some  Continental  authors,  after  first  giving  some  such  definition  as  the  above, 
go  on  to  describe  passive  concentric  movements,  during  which  the  assistant  resists, 
and  passive  excentric  ones,  during  which  the  patient  resists  ! 


CHAPTER  IIT. 

GYMNASTIC    POSITIONS. 

I  SHALL  now  proceed  to  a  brief  description  of  the  more 
important  gymnastic  positions  as  utilised  by  Henrik  Kellgren 
although  they  are  in  most  cases  practically  identical  with  the 
corresponding  ones  in  Ling's  system. 

It  has  previously  been  explained  what  is  meant  by  a  gymnastic 
position,  and  it  must  be  emphatically  insisted  upon  that  the 
accuracy  of  any  such  position  is  absolutely  essential  to  the  j^roper 
performance  of  the  movement  or  movements  to  follow. 

Gymnastic  positions  are  divided  into  . — 
I. — Fundamental. 
II. — Secondary  or  Derived. 

I. — Fundamental  Positions, — These  are  five  in  number  : — 
(1)  Standing,  ('2)  sitting,  (3)  lying,  (4)  kneeling,  (5)  hanging. 

(1)  Standing  position} — The  patient  stands  so  that  the  heels 
are  together,  the  feet  at  right  angles,  the  knees  straight,  the 
trunk  erect  and  stretched,  the  abdomen  drawn  somewhat  in, 
the  chest  well  forward,  the  shoulders  drawn  down  and  back,  the 
head  erect  with  the  chin  drawn  in.  The  arms  hang  by  their  own 
weight,  the  palms  resting  against  the  thighs  (fig.  1). 

(2)  Sitting  position. — The  patient  sits  so  that  the  arms,  trunk 
and  head  are  placed  as  in  the  previous  position,  while  the  knees 
and  thighs  are  flexed  to  a  right  angle  and  the  feet  in  their  entire 
length  rest  on  the  ground  (fig.  2). 

(3)  Lying  position. — The  patient  rests  from  head  to  heels  on 
a  horizontal  couch,  the  arms  lying  along  the  sides  (fig.  3).  In 
pedagogical  gymnastics,   where   the   subject   has  to  stretch  the 

'Iq  Brantiug's  "  Efteiiemnade  Skrifter,"  1882,  many  details  conocruing  the 
commonest  mistakes  in  taking  up  initial  positions  can  be  found  (part  i.  "  Bran- 
ting's  termiuologie,"  pp.  1-115,  ctseq.).  See  also  Silow's  "  Handbok  i  gymnastik  for 
Armeen  och  Plottau,"  1902,  vol.  i. 


GYMNASTIC  POSITIONS 


trunk  and  limbs  as  much  as  possible,  this  is  not  a  position  of 
perfect  rest;  but  it  is  so  in  medical  g3'ninastic-i  where  no  such 
stretching  is  needed.' 


Fig.  3. 

(4)  Kneeling  position. — In  pedagogical  gymnastics  the  subject 
assumes  the  position  on  the  floor,  kneeling  so  as  to  rest  on  knees 
and   toes,   the   ankle   joints   being   fully   extended.     In   medical 

'  Cf.  Wide's  "  Handbok  i  Mediciusk  Gymuastik,"  1895,  p.  14.  Wide's  "Haad- 
book  of  Medical  Gymnastics,"  1899,  p.  13.  Wide's  "  Handbok  i  Medicinsk  ocli 
Ortopedisk  Gymnastik,"  1902,  p.  14.  Wide's  "  Handbook  of  Medical  and  Orthopiedic 
Gymnastics,"  1903,  p.  2.  See  also  Prode  Sadolin,  "  Liggande  grundstaUning  soni 
livilestiUing  "  in  Tidskrift  i  Gymnasiik,  1902,  p.  341,  &c. 


16     ELEMENTS  OF  KELLGREN'S    MANUAL   TREATMENT 

gymnastics,  however,  the  patient  assumes  this  position  on  a 
couch,  resting  on  knees  and  insteps,  so  that  the  toes  hang  over 
one  end  (fig.  4).^ 

(5)  Hanging  position. — The  patient  is  suspended  by  the  arms, 
which  are  stretched  vertically  upwards  ;  the  jjalms  look  forwards 
and  grasp  a  horizontal  beam  (fig.  5). 

II. — Secondary  Positions. — By  these  are  meant  positions 
derived  primarily  from  the  fundamental  ones  or  secondarily  from 
one  another,  by  causing  the  arms,  legs,  head  or  trunk,  either  one 
or  several,  in  whole  or  in  part,  to  assume  certain  new  positions, 
the  rest  of  the  body  being  kept  in  its-  original  posture. 

Terminology. — It  is,  of  course,  necessary  to  have  some  brief 
method  of  naming  these  new  positions.  It  would  obviously  be 
cumbrous  and  unpractical  to  say  "  the  arms-stretched-vertically- 
upwards-feet-two-foot-lengths-apart-sideways-trunk-and-head-as- 
before  position."  In  order  to  abbreviate  as  much  as  possible  and 
yet  to  give  a  clear  idea  of  what  is  referred  to,  the  following 
arrangement  is  the  one  that  is  generally  adopted  : — 

Firstly,  the  change  (if  any)  in  the  position  of  the  arms  is 
indicated ;  and  in  the  example  just  given  the  one  word  "  stretch  " 
would  be  used  to  replace  the  four  words  "  arms  stretched  verti- 
cally upwards."  Secondly,  the  change  (if  any)  in  the  position  of 
the  legs  is  added,  in  this  particular  case  the  word  "  stride "  ; 
thirdly,  the  change  (if  any)  in  the  position  of  the  trunk  ;  and 
lastly,  the  original  position  in  which  the  body  was  placed 
before  these  changes  were  brought  about.  Thus  the  example 
given  above  would  be  expressed  clearly  and  concisely  by  the 
term   "  stretch  stride  standing." 

Any  such  terminology  must  sound  strange  at  first,  but  it  is 
after  all  the  best,  being  the  most  succinct  and  the  most  definitive. 
It  was  invented  by  Branting,  who  worked  it  out  some  seventy 
years  ago  at  P.  H.  Ling's  instigation,  and  under  his  supervision, 
to  replace  the  old  terminology  which  was  longer,  somewhat 
cumbrous,  and  often  quite  ambiguous. 

In  the  following  account  of  the  secondary  or  derived  positions 

'  This  method  of  assuming  the  kneeling  position  gives  much  greater  security  of 
balance  than  the  one  advocated  by  Wide,  in  which  the  patient  is  supported  only  by 
the  knees  and  legs.  Sec  Wide's  "  Handbok  i  Medioinsk  Gymuastik,"  1895,  p.  15. 
"  Handbook  of  Medical  Gymnastics,"  1899,  p.  14.  "  Handbok  i  Medicinsk  och 
Ortopedisk  Gymnastik,"  1902,  p.  15.  "Handbook  of  Medical  and  Orthopaedic 
Gymnastics,"  1903,  p.  129. 


GYMNASTIC  POSITIONS 


17 


onl)'  the  parts  specially  concerned  will  be  referred  to  ;  it  must  be 
taken  for  granted  that  the  position  of  the  rest  of  the  body  is 
strictly  the  same  as  in  the  original  position  from  which  the  new 
one  is  derived. 


(A)     Positions  derived  from  the  Standing  Position. 


I. — Bij  Moving  the  Arinfi. 

(1)  Hips  firm,  or  wing,  standing. — The  hands  are  placed  on 
the  hips  so  that  the  palms  rest  against  the  crests  of  the  ilia  with 
the  fingers  anteriorly  and  the  thumbs  posteriorly ;  the  elbows  and 
shoulders  are  well  drawn  back  (fig.  9).    ,■ 

(2)  Bend  standing. — The  arms  ar0  bent  by  flexion  at  the 
elbows ;  the  forearms  are  in  extreme  flexion  and  supinated  ;  the 
wrists   and  fingers  are   somewhat   fieked   and   the   latter   touch 

2 


1 8     ELEMENTS   OF   KELLGREN'S   MANUAL    TREATMENT 

the   upper   arms   in   front  of  the    head   of   the   humerus.      The 
upper  arms  are  to  some  extent  externally  rotated  (fig.  6). 

(3)  Sicim  standing. — The  arms  are  placed  in  front  of  the 
chest  just  as  in  the  first  position  of  swimming.  The  upper  arujs 
are  abducted  to  a  right  angle,  and  the  elbows  kept  well  back  ; 
the  forearms  are  in  extreme  flexion  and  also  horizontal ;  the 
palms  of  the  hands  look  directly  downwards  (fig.  40). 


(4)  Heave  standing. — The  upper  arms  are  stretched  hori- 
zontally outwards ;  the  elbows  are  flexed  to  a  right  angle,  so 
that  the  forearms  and  fingers  point  vertically  upwards,  and  are 
either  supinated,  in  the  mid-position,  or  pronated,  i.e.,  the  palms 
either  look  directly  inwards,  directly  forwards,  or  directly  out- 
wards (fig.  19). 

Heave  lean  standing. — "  Lean  "  means  that  some  part  of 
the   body  rests  against   some    fixed  apparatus   for  support.     In 


GYMNASTIC   POSITIONS  19 

this  case  suppoit  is  obtained  by  means  of  two  vertical  poles,  or 
some  such  apparatus,  against  which  the  forearms  and  hands  rest ; 
to  allow  of  this  the  former  must  be  in  the  mid-position  (fig.  63). 

Heave  grasp  standinq. — "  Grasp "  means  that  the  hands 
grasp  some  fixed  apparatus  in  order  to  obtain  support.  This 
position  is  the  same  as  the  last,  excepting  that  the  hands  grasp 
the  poles  instead  of  merelj'  resting  agamst  them  (fig.  77). 

In  both  heave  lean,  and  heave  grasp  positions  the  individual 
should  lean  forwards  a  little  in  order  to  expand  his  chest  better. 

(5)  Stretch  standing. — The  arms  are  stretched  vertically 
upwards,  and  are  kept  parallel,  with  the  palms  of  the  hands 
looking  towards  one  another  (fig.  7). 

Stretch  grasj)  standing  is  the  same  as  the  previous  position, 
but  the  hands  grasp  either  the  rung  of  a  ladder  placed  at  a 
suitable  height,  or  else  two  vertical  poles.  This  position  may 
also  be  called  stretch  span  standing  (fig.  .59). 

Stretch  grasp  side  standing. — The  patient  stands  sideways 
against  a  ladder ;  the  arm  nearest  to  it  is  stretched  vertically 
downwards  and  grasps  one  of  its  rungs.  The  oirter  arm  is 
stretched  upwards  and  somewhat  inwards,  and  also  grasps  a 
rung  (fig.  CO).     This  position  is  often  called  side  span  standing. 

(6)  Beach  standing. — The  arms  are  stretched  horizontally 
forwards  and  lie  parallel ;  the  palms  of  the  hands  look  directly 
towards  one  another  (fig.  -58). 

Reach  grasp  standing  is  the  same  as  the  last,  excepting  that 
the  hands  grasp  a  suitable  support,  such  as  the  rung  of  a  ladder 
(fig.  81). 

(7)  Yard  standing. — The  arms  are  stretched  horizontally 
outwards,  or  even  a  little  backwards,  the  palms  of  the  hands 
look  either  directly  downwards,  directly  forwards,  or  directly 
upwards  (fig.  8). 

(8)  Neck  firm,  or  rest,  standing. — The  hands  are  placed 
behind  the  neck,  the  elbows  are  flexed  and  kept  well  back,  the 
forearms  are  pronated ;  the  fingers  rest  on  the  lower  part  of  the 
occipital  bone,  just  about  the  protuberance  (fig.  37). 

In  many  duplicate  movements  this  position  is  difficult  to 
maintain,  the  head  and  elbows  having  a  strong  tendency  to 
come  forward.  This  can  be  remedied  by  letting  the  patient 
place  his  fingers  over  the  posterior  part  of  the  parietal  bones  ; 
much  of  the  exertion  which  was  necessary  before  is  eliminated 
by  so  doing. 


20     ELEMENTS  OF  KELLGREN'S   MANUAL    TREATMENT 


Fig.  8. 


GYMNASTIC   POSITIONS  21 

II. —  By  Moving  the  Legs. 

(1)  Toe  standing. — From  the  fundamental  position  the  patient 
raises  himself  on  tiptoe,  keeping  his  heels  together.  The  trunk 
and  legs,  moving  as  a  whole,  must  come  forwards  a  little,  so 
as  to  preserve  the  equilihrium. 

(2)  Knee  bend  toe  standing. — From  the  toe  standing  position 
the  knees  are  bent  outwards  until  the  thigh  and  lower  leg 
are  at  right  angles   (fig.  9). 

(3)  Walk  standing. — One  foot  is  placed  two  foot  lengths 
directly  forwards ;  the  trunk  passes  forwards  so  as  to  rest  equally 
on  both  feet  (fig.  10). 

Hip  lean  walk  standing  is  the  same  as  the  last,  excepting  that 
support  is  granted  to  one  side  between  the  great  trochanter  and 
crest  of  the  ilium  by  means  of  a  bar  or  other  suitable  support 
placed  horizontally  and  parallel  to  the  sagittal  plane.  The 
support  should  be  on  that  side  on  which  the  foot  is  anterior 
(fig.  37). 

(4)  Stride  standing. — The  feet  are  placed  sideways  two  foot 
lengths  apart,  the  weight  of  the  body  resting  equally  on  both 
(fig.  7). 

Loin  lean  stride  standing  is  the  same  as  the  last,  excepting 
that  the  upper  sacral  region  rests  against  a  bar  or  other  suitable 
support  placed  horizontally  and  parallel  to  the  coronal  plane 
(fig.  38). 

Leg  lean  stride  standing. — The  patient  is  in  stride  standing 
position;  his  feet  are  fixed  and  the  front  of  the  upper  thirds  of 
his  thighs  rest  against  a  bar  also  placed  horizontally  and  parallel 
to  the  coronal  plane. 

(5)  Step  standing. — One  foot  is  placed  on  the  rung  of  a  ladder 
or  some  other  suitable  support,  the  hip  and  knee  joints  of  that 
side  being  flexed  to  about  a  right  angle. 

Instead  of  being  merely  flexed,  the  tliigh  may  be  rotated 
externally  and  abducted  as  well. 

III. — Bij  Moving  the  Trunk. 

(1)  Arch  standing. — The  spinal  column  in  its  dorsal  and 
cervical  regions  is  extended  backwards  on  itself ;  naturally  the 
pelvis  must  be  carried  slightly  forward  in  order  to  preserve  the 
equilibrium. 


22     ELEMENTS   OF   KELLGREN'S   MANUAL    TREATMENT 

Head  lean  arch  standing. — Standing  with  bis  back  towards  a 
wall,  one  foot  length  from  it,  the  patient  arches  his  back  as  just 
described  until  his  head  rests  against  the  wall  (fig.  35). 

(2)  Side  bend  standing. — The  trunk  is  flexed  laterally  well 
over  to  one  side,  care  being  taken  to  protrude  neither  shoulder 
nor  hip  (fig.  36). 

(3)  Tu7'n  standing. — The  trunk  is  rotated  to  one  side  on  its 
long  axis,  care  being  taken  to  move  the  hips  as  little  as  possible. 

Loin  lean  turn  standing.— The  sacrum  is  supported  as  already 
described  in  order  to  fix  the  hips  better.  The  feet  are  usually 
placed  as  for  stride  position  ;  this  results  in  loin  lean  stride  turn 
standing  position  (fig.  46). 

(4)  Stoop  falling  (also  called  stoop  fall  standing). — The  whole 
body  leans  forwards,  the  hands  are  in  reach  position,  either 
leaning  against  or  grasping  a  support  so  as  to  maintain  the 
immovable  position  (fig.  17). 

(B)   Positions  Derived  from  the  Sitting  Position. 

(a)  Low  sitting. — The  patient  sits  on  a  low  chair. 
(6)  High  sitting. — The  patient  sits  on  a  high  chair. 
Both  of  these  variations  are  merely  for  the  convenience  of  the 
assistant. 

I. — By  Moving  the  Arms. 

(1)  Hips  firm  sitting,  (2)  swim  sitting,  (3)  heave  sitting, 
(4)  stretch  sitting,  (5)  reach  sitting,  (6)  yard  sitting,  (7)  neck 
firm  sitting ;  the  particulars  of  which  can  be  grasped  without 
difficulty  from  the  descriptions  already  furnished  of  the  corre- 
sponding standing  positions.  In  any  of  them  the  patient  may, 
if  necessary,  have  his  back  supported. 

II. — Bij  Moving  the  Legs. 

(1)  Bide  sitting. — The  patient  sits  astride  on  a  chair  or  couch, 
his  feet  resting  on  the  ground  or  some  other  support.  The  feet 
and  knees,  or  only  the  former,  may  have  to  be  fixed  to  ensure 
stability  (fig.  39).  This  position  may  also  be  called  simply 
"  riding." 

(2)  Stride  sitting. — This  usually  replaces  the  ordinary  sitting 
position  in  order  to  secure  better  balance  by  means  of  a  larger 


GYMNASTIC    POSITIONS  23 

area  of  support.     The  feet  are  kept  well  apart,  and  the  lower  legs 
perpendicular  (fig.  19). 

111.— By  Moving  the  Trunk. 

(1)  Sit  Ii/ing.— The  head,  trunk,  and  thighs  are  as  in  the 
fundamental  lying  position  ;  the  knees  are  flexed  to  a  right  angle, 
and  the  lower  legs  hang  over  the  edge  ot  the  couch  on  which  the 
position  was  assumed  (fig.  11). 


(2)  Fall  sitting. — The  trunk  and  head  are  kept  midway 
hetween  sitting  and  sit  lying  positions,  thus  forming  an  angle 
of  about  185°  with  the  thighs  anteriorl}-.  The  lower  legs  must 
be  fixed  (fig.  33). 

(C)     Positions   Derived   fkom  the  Lying  Position. 

I. — Bij  Moving  the  Anns. 

(1)  Hips  firm  lying ;  (2)  Heave  lying ;  (3)  Stretch  lying ; 
(4)  Neck  firm  lymg,  &c.,  the  particulars  of  which  can  be  grasped 
without  difficulty  from  the  descriptions  already  furnished  of  the 
corresponding  standing  positions. 

II. — Bij  Muring  flie  Legs. 

Crook  lying. — The  patient's  trunk  and  head  are  as  in  lying 
position ;  the  knees  are  drawn  up  with  the  heels  resting  on  the 
couch  (fig.  12). 


24     ELEMENTS    OF  KELI.GREN'S    MANUAL    TREATMENT 


III. — Bij  Moving  the  Trunk. 

(1)  Half  lying. — The  patient  reclines  backwards  on  a  couch, 
so  that  while  the  legs  are  horizontal,  the  trunk  and  head  form  an 
obtuse  angle  with  the  legs.  The  angle  may  be  increased  or 
diminished  according  to  circumstances  (fig.  41). 

From  this  may  be  derived  hips  firm,  stretch,  heave,  &c.,  half 
lying  position  according  to  the  placing  of  the  arms. 

(2)  Crook  half  lying. — Is  a  combination  of  crook  lying  and 
half  lying  position.  In  some  cases  the  hip-joints,  instead  of 
merely  undergoing  flexion,  may,  in  addition,  be  externally  rotated 
and  abducted  ;  i.e.,  the  knees  are  separated  (fig.  13). 


(3)  Forwards  lying. — The  patient  lies  prone  with  face  down- 
wards and  spinal  column  arched,  supporting  the  latter  with  the 
forearms  (fig.  14). 


GYMNASTIC  POSITIONS 


25 


Arch  forwards  lying. — The  patient's  feet  are  first  fixed  by  the 
assistant ;  the  former  then  arches  the  spinal  column  backwards 
(extends  it  on  itself)  as  much  as  possible  ;  the  arms  are  usually  in 
hips  firm  position  (fig.  34). 

(4)  Side   lying. — The   patient    lies   on  one   side   on   a  couch 
fig.  15). 


p^lM 

i 

^^~ 

"1 

m 

i 

^^^t^p 

1 

Stretch  side  lying  is  the  same  as  the  last,  excepting  that  the 
uppermost  arm  is  in  stretch  position,  i.e.,  in  right  side  lying  the 
left  arm  is  moved,  and  vice  versa. 


(D)     Positions  Derived  from  the  Kneeling  Position. 

I. — By  Moving  the  Arms. 
Such  positions  result  as  neck  firm  kneeling,  &c. 

II. — By  Moving  the  Legs. 
There  is  only  one  in  ordinary  use,  i.e.,  stride  kneeling,  which. 


26     ELEMENTS  OF  KELLGREN'S   MANUAL    TREATMENT 

from  the  greater  security  of  balance  afforded  bj'  it,  in  practice 
entirely  replaces  kneeling  position.  The  knees  are  separated  by 
about  a  foot's  length,  but  the  heels  are  kept  together  as  before 
(fig.  84). 

III. — By  Moving  the  Trunk. 

Such  positions  result  as  turn  kneeling,  side  bend  kneeling, 
&c. 

From  the  foregoing  an  innumerable  number  of  other 
secondary  positions  may  be  derived  by  the  simple  process  of 
combination,  such  as  stretch  arch  forwards  lying,  neck  firm 
loin  lean  stride  turn  standing,  &c. 


CHAPTER  IV. 

GENERAL    PHYSIOLOGICAL    EFFECTS    OF   ACTIVE 
AND    PASSIVE    MOVEMENTS. 

(A.) — Physiological  Effect  of  Purehj  Active  Movements. 

Purely  active  movements  are  seldom  prescribed  in  Kellgren's 
treatment,  as  in  almost  all  cases  a  greater  effect  can  be  obtained 
by  substituting  the  corresponding  duplicate  exercises ;  and  it  is 
unnecessary  to  describe  the  physiological  effects  of  the  former,  as 
they  are  in  a  lesser  degree  much  the  same  as  those  of  the  latter. 
Should,  however,  no  corresponding  duplicate  form  be  in  ordinary 
use,  the  effects  of  the  purely  active  movement  will  be  described 
in  the  proper  place  immediately  after  the  description  of  the  move- 
ment itself. 

(B.) — Physiological  Effect  of  Duplicate  Movements. 

This  part  of  the  subject  will  be  treated  in  considerable  detail, 
and  the  advantages  possessed  by  duplicate  movements  over  the 
ordinary  purely  active  ones  clearly  pointed  out. 

Special  effects  of  the  "  traction." — The  effects  of  the  traction 
applied  in  every  duplicate  movement  are  as  follows  : — 

(1)  The  muscles  are  rendered  capable  of  doing  more  work  ; 
because  the  more  a  muscle  is  elongated  within  its  physiological 
limit  the  greater  becomes  its  absolute  power. 

(2)  There  is  increased  absorption  by  the  lymphatics,  due  to 
the  stretching  of  the  vessels  themselves  as  well  as  of  the  fasciae, 
tendons,  ligaments,  &c.,  of  the  part.  In  all  the  structures  just 
mentioned  there  are  two  sets  of  these  lymphatics,  a  deep  set,  and 
a  superficial  set,  connected  by  small  branches.  The  slightest 
pressure  or  stretching  of  the  tendons,  &c.,  causes  a  flow  of  lymph 
from  the  deep  into  the  superficial  set,  the  latter  in  their  turn 
discharging  their  contents  into  the  larger  lymphatic  trunks.  On 
removal  of  the  pressing  or  stretching  force,  new  lymph  is  sucked 


j8    elements  of  kellgren's  manual  vreatment 

from   the   tissues  into  the   deep  set,  and  so  on.'     (Ludwig  and 
Sch  weigger-Seidel)  .- 

(3)  The  longitudinal  blood-vessels  are  elongated  ;  the  veins, 
therefore,  have  their  actual  capacity  increased,  and  a  suction 
power  arises  in  them  (see  also  page  30). 

(4)  The  absolute  range  of  mobility  of  joints  is  in  some  cases 
increased.  The  opposing  articular  surfaces  are  separated  from 
one  another,^  or  their  mutual  pressure  diminished,  by  a  with- 
drawing of  the  elastic  tension  of  the  muscles  and  ligaments,  and 
thus  any  pain  from  inflammation,  friction,  &c.,  is  reduced  to  a 
minimum.     The  ligaments  are  elongated  and  stimulated. 

(5)  The  nerves  become  stimulated  by  means  of  moderate 
elongation.  This  is  one  of  the  most  important  effects.  Although 
many  physiologists  had  experimented  on  the  effect  of  elongation 
of  nerves  before ''  Tigerstedt  did  so,  I  think  I  am  right  in  saying 
that  he  was  the  first  to  clearly  demonstrate  that  a  slight  amount 
of  stretching  greatly  increased  the  excitability  of  a  nerve,  whereas 
a  considerable  amount  did  the  opposite.'  His  results  have  since 
been  confirmed  by  other  observers. 

Effects  on  Different  Parts  of  the  Organism. 
I. — Bloocl-Vcssels  and  Blood. 

(1)  In  the  case  of  a  concentric  movement. — Physiologists  are 
not  quite  agreed  as  to  the  precise  nature  of-  the  sequence  of 
events  resulting  in  the  circulation  of  the  blood  during  and  after 
muscular  contraction,  but  the  following  as  nearly  as  possible 
represents  their  general  opinion : — 

(a)  In  the  contracting  muscles.  The  longitudinal  blood- 
vessels, arterial  and  venous,  are  shortened,  and  all  the  vessels 
of  the  part  subjected  to  pressure  by  the  contracting  muscles.  The 
first  effect  on  the  arteries  is  an  increase  in  the  velocity  of  their 
contents,  the  vis  a  tergo  preventing  movement  in  the  opposite 
direction.     The  first  -effect  on  the  veins  is  a  considerable  diminu- 

'  In  medicine  a  good  deal  is  heard  about  vicious  circles ;  in  gymnastics,  as  in 
this  particular  case,  instances  frequently  arise  of  dealing  with  beneficial  ones. 

•'  "  Die  Lymphgefasse  der  Pascien  und  Sehnen,"  1872.     See  also  p.  32. 

■'  The  amount  of  force  necessary  to  separate  the  articular  surfaces  differs,  of 
course,  in  different  joints.  According  to  Haycraft,  for  the  hipjoint  the  amount  is 
about  20  kilos.,  for  a  metacarpo-phalangeal  joint,  about  J  kilo.  (C/.  Schi-ifcr, 
"  Textbook  of  Physiology,"  vol.  ii.,  1900,  pp.  234,  235.) 

'  A  list  of  the  literature  of  the  subject  can  be  found  in  Stintzing's  "  UberNerveu- 
dehnung,"  1883. 

=■  "  Studien  iiber  Mechanische  Nervenreizung,"  1880,  pp.  39,  &c. 


EFFECTS  OF  ACTIVE  AND    PASSIVE    MOVEMENTS      29 

tion  in  their  volume,  their  contents  being  sent  on  in  a  spurt 
towards  the  heart.  As  contraction  proceeds,  a  rise  in  the  local 
arterial  resistance  takes  place,  and  the  contents  of  the  inter-  and 
intra-muscular  veins  are  squeezed  into  the  larger  trunks.  As 
soon  as  relaxation  takes  place,  or  even  in  some  cases  during  the 
last  part  of  the  contraction,  there  is  a  considerable  vaso-dilatation 
of  the  arteries,  arterioles,  and  capillaries,  and  thus  more  blood 
will  flow  to,  through,  and  from  the  contracting  muscles  in  a  unit 
of  time.'  In  consequence  of  this  dilatation  the  local  peripheral 
resistance,  which  is  cliiefl}' arteriolar  (Foster,^  Campbell,''  Oliver^), 
is  greatly  reduced,  and  the  capillary  pressure  rises  above  what 
it  was  before  the  muscle  began  to  contract.  The  circulation 
through  the  muscle  becomes  much  more  lively,  and  the  metabolism 
of  the  muscle  is  greatly  increased  ;  this  effect  passes  ofl^  gradually, 
although  it  may  often  be  noticeable  for  an  hour  or  more." 

'  This  was  known  practically  by  tlae  Ling  school  before  it  was  proved  by 
physiologists.  P.  H.  Ling  speaks  of  derivative  or  depleting  exercises  in  "  Gymnas- 
tikens  Allmiinna  Grander  "  (18.34)  1340,  pp.  153,  159,  &c.  {see  p.  31).  See  also 
Sondt-n,  "  Tankar  ofver  Praktisk  Mediciu,"  in  Hygeia,  March,  1840,  p.  119;  the 
works  of  Neumann,  Rothstein,  &c. 

■-■  "  Textbook  of  Physiology,"  1891,  p.  209. 

^  "  The  Resistance  to  the  Blood-flow,"  in  Journal  of  Physiology,  1898,  vol.  xxiii., 
pp.  301-309. 

<  "The  Blood  and  Blood  Pressure,"  1901,  pp.  141,  142. 

^  The  foregoing  facts  are  taken  from:  —01.  Bernard,  "  Le<,-ons  sur  les  proprietes 
physiologiques  et  les  alterations  pathologiques  des  liquides  de  I'organisme,"  1859, 
p.  325,  &c.  Sczelkow,  "  Zur  Lehre  vom  Gasumtausch  in  verschiedeuon  Organeu,''  in. 
Zeitschr.  fiir  Rat.  Med.,  1863,  vol.  xvii.,  pp.  106,  122,  &c.,  also  in  "Sitzungs 
Berichte  der  Akad.  d.  Wissensch.  Math-Naturw.  Kl.,"  vol.  xiv.,  Zweite  Abtheiluug 
pp.  471,  &o.  Sadler,  "  Uber  den  Blutstrom  in  den  ruheudeu,  verkurzteu  uud  ermiid- 
eten  Muskeln  des  lebenden  Thieres,"  in  Arbeiten  a.  d.  Phys.  Anst.  su  Leipzig,  1869, 
pp.  77-100.  Haflz,  "  Uber  die  motori.schen  Nerven  der  Arterien,  welche  inuerhalb 
der  quergestreiften  Muskeln  verlaufen,"  in  Arb.  a.  d.  Phys.  Anst.  z.  Leipzig,  1870, 
pp.  95-112.  Ranvier,  "  Note  sur  les  vaissaux  sanguius  et  la  circulation  dans  les 
muscles  rouges,"  in  Archives  de  Phys.,  1874,  p.  448.  Gaskell,  "Uber  die  Ande- 
rungen  des  Blutstroms  in  den  Muskeln  durch  die  Reizung  ihrer  Nerven,"  in  Arb.  a.  d. 
Phys.  Anst.  zu  Leipzig,  187G,  pp.  45-88  ;  also  "  Further  Researches  on  the  Vaso- 
motor Nerves  of  Ordinary  Muscles,  "  in  Journal  of  Phys.,  vol.  i.,  1878,  pp.  262,  &c. 
Mosso,  "  Sulle  variazioni  locali  del  polso  nell'  antibraccio  del  uomo,"  1878.  Marey, 
"La  Circulation  du  Sang,"  1881,  pp.  343,  &c.  Humilewski,  "Uber  den  Einfluss 
der  Muskelcontractiou  der  Hinterextremitat  auf  ihre  Blutcirkulation,"  in  Arch.  f. 
Anal.  u.  Phys.,  Phys.  Abth.,  1886,  p.  126.  Spaltholz,  "  Die  Gefassvertheilung 
im  Muskel,"  Abhandl.  der  Konigl.  Sachs.  Gesellsch.  zur  Wissensch.,  1888,  No.  11. 
Kaufmann,  "  Recherches  experimentales  sur  la  circulation  dans  les  muscles  en 
activity  physiologique,"  in  Archives  de  Phys.,  1892,  p.  279.  Hasebroek,  "Die 
Gymnastische  Widerstandsbewegungen  in  der  Therapie  der  Herzkrankheiten,"  1895. 
Brunton  and  Tuuuicliffe,  "  Remarks  on  the  Effect  of  Resistance  Exercises  upon 
the  Circulation  in  Man,  local  and  general,"  in  Brit.  Med.  Journ.,  1897,  vol.  ii., 
pp.  1073,  &c.  Oliver,  "The  Blood  and  Blood  Pressure,"  1901.  Heilemann,  "Das 
Verhalten  der  Muskelgefasse  wahrend  der  Contraction,"  in  Arch.  f.  Anat.  u.  Phys., 
Anat.  Abtheil.,  1902,  pp.  45,  &o.     See  also  literature  on  p.  30. 


30     ELEMENTS   OF   KELLGREN'S  MANUAL    TREATMENT 

Sadler '  made  the  interesting  observation  that  if  resistance  is 
offered  to  a  contracting  muscle  so  as  to  prevent  its  shortening, 
considerably  more  blood  passes  through  it  in  a  unit  of  time 
than  if  it  is  allowed  to  conti'act  without  an  opposing  force. 
This  is  in  all  probability  due  to  stimulation  of  the  muscle  to 
do  more  work  by  the  resistance  offered  (isometric  contrac- 
tion), and  because  the  effect  of  the  mechanical  pressure  through 
shortening  and  increase  in  the  sectional  area  of  the  muscle  is 
largely  eliminated. 

The  relative  amounts  of  blood  in  resting  and  active  muscle 
have  been  varyingly  estimated.  Kanke-  stated  them  to  be  as 
about  86'(5  per  cent,  and  66  per  cent,  respectively  of  the  total 
blood  quantum;  Spehr^  as  0-3'27  to  0-343  and  0-.520  to  0  664. 
Kaufmann^  found  from  three  to  five  times  as  much  blood 
How  through  a  muscle  during  activity  as  during  rest ;  Hill 
and  Nabarro'"  found  the  same.     See  also  Oliver.* 

The  venous  flow  is  in  many  places  promoted  by  the  exist- 
ence of  special  anatomical  mechanisms  which  aid  it.  In  most 
of  the  joints  of  the  body,  but  especially  at  the  hip,  knee, 
shoulder,  and  lower  part  of  the  neck,  the  veins  are  attached 
to  tendon  sheaths,  fasciae,  &c. ;  the  latter  are  stretched  in 
many  movements,  and  thus  the  walls  of  the  veins  are  opened 
out  and  a  suction  power  is  set  up  in  them.  (This  is  quite 
apart  from  the  one  induced  by  respiration.)  When  the  fasci;¥, 
&:c.,  are  relaxed  the  veins  have  their  lumen  diminished,  and 
their  contents  are  sent  on  towards  the  heart,  the  valves  pre- 
venting any  reflux^  (Braune,''  Herzog").  The  importance  of 
the    suction    power   in    the   veins   is    still   further   increased   by 


'  "tjber  den  Blutstrom  in  den  ruheuden,  verklirzten  und  ermiideten  Jluskeln  des 
iebeuden  Thieres,"  in  Arbeiten  an  der  Phys.  Anst.  zu  Leipzig,  1869,  p.  77. 

-  "  Die  Blutvertheilung  und  der  Thiitigkeitswechsel  der  Organe,"  1871,  p.  88. 

'  "  De  la  reparition  du  sang  circulaut  dans  I'economie,"  These,  Bruxelles,  1883. 

^"Recherches  experimentales  sur  la  circulation  dans  les  muscles  en  activite 
pbysiologique,"  in  Arch,  de  Pliys.  normale  et  pathologique,  1892,  p.  28.3,  &c. 

^  "  On  the  exchange  of  Blood  Gases  in  Brain  and  Muscle  during  states  of  rest 
and  activity,"  in  Journal  of  Physiology,  1895,  vol.  xviii.,  p.  218. 

"  "  The  Blood  and  Blood  Pressure,"  1901,  p.  157. 

■  This  was  known  and  practically  demonstrated  by  the  Ling  school  years  before 
its  actual  demonstration  by  Braune.  (See  Hj.  Ling  in  Branting's  "  Ef terlemnade 
Skrifter,"  1882,  p.  xxx.). 

"  "  Die  Oberschenkelvene  in  anatomischer  u.  klinischer  Beziehung,"  1873. 

"  "Beitriige  zum  Mechanismus  der  Blutbewegung  an  der  oberen  Tboraxapertur 
beim  Menschen,"  in  Deutsche  Zeitschrift  fur  Chirurgic,  1881,  vol.  xvi.,  pp.  1  30. 


EFFECTS  OF  ACTIVE  AND  PASSIVE  MOVEMENTS       31 

the  fact  that  in  most  places  where  such  mechanisms  exist  the 
number  of  venous  tributaries  greatly  exceeds  the  corresponding 
number  of  arterial  stems  (Braune').  In  all  sites  where  muscles 
by  their  contraction  compress  the  veins  and  thus  further  their 
flow  in  a  centripetal  direction,  these  vessels  are  arranged  in 
pairs,  one  on  each  side  of  its  artery  (Braune  ')• 

(b)  In  the  antagonistic  muscles.  The  longitudinal  vessels  are 
elongated ;  thus  the  veins  have  their  actual  capacity  increased, 
and  a  suction  power  is  set  up  in  them.  The  circulation,  both 
venous  and  arterial,  will  thus  be  hastened. 

(2)  In  the  case  of  an  excentric  movement. — («)  In  the  con- 
tracting muscles.  The  effects  will  be  nearly  similar  to  those 
taking  place  in  the  case  of  a  concentric  movement,  but  there 
is  hardly  any  rise  in  the  local  arterial  resistance,  and  probably 
vaso-dilatation,  instead  of  only  occurring  after  the  contraction, 
commences  together  with  it. 

(b)  In  the  antagonistic  muscles.  The  shortening  of  the  longi- 
tudinal veins  causes  a  diminution  in  their  volume ;  thus  their 
contents  are  driven  on  towards  the  heart. 

From  the  above  details  it  is  clear  that,  in  giving  a  duplicate 
exercise,  blood  will  be  drawn  to  the  muscles  that  are  active, 
and  this  must  be  compensated  for  by  less  blood  in  some  other 
muscle  or  organ.  In  gymnastics  movements  that  draw  away  blood 
are  called  "depleting"  or  "derivative";  thus  exercising  both 
arms  and  both  legs  causes  depletion  of  the  trunk. ^ 

Depleting  effects  may  be  brought  about  in  large  or  in  small 
areas ;  in  illustration  of  the  second  it  may  be  stated  that,  as  a 
general  rule,  exercises  entailing  action  of  the  abductors  of  the 
thigh  cause  depletion  of  the  pelvic  organs.  Clinical  experience 
tends  to  show  that  after  depletion  of  a  part  a  reaction  sets  in, 
which  is  complete  in  normal  states,  but  only  partial  in  patho- 
logically inflamed,  hyperaeiuic,  or  congested  states  ;  thus  im- 
provement results. 

Effect  of  active  movements  on  the  blood  itself. — The  majority 
of  observers  are  agreed  that  all  muscular  exercise,  whether  active 
or   passive,    causes    an   mcrease    in    the    percentage    of    the    red 


■  Op.  cit.,  p.  9. 

-  P.  H.  Liug  makes  several  references  to  such  depleting  (called  "  afledaude ' 
Swedish)  movements  iu  "  Gymnastikens  Allmanna  Grander"  (18-34),  1810. 


32     ELEMENTS  OF  KELLGREK'S    MANUAL    TREATMENT 

corpuscles.     (Malassez,'  Wintemitz,'-  Mitchell,^  Cheron,'  Oliver.^ 
Cf.,  however,  Edgecombe.'') 

II. — Lymph. 

Normall)'  in  a  part  at  rest  there  iS  very  httle  flow  of  Ij'mph, 
some  authorities  say  none  at  all  (Starling"),  hut  both  active  and 
passive  movements  increase  its  production  and  favour  its  flow% 
as  first  shown  by  Genersich,'  Lesser,"  and  Paschutin,"^'  in  Ludwig's 
laboratory.  The  special  mechanisms  that  exist  in  the  anatomical 
arrangement  of  the  lymphatics  have  been  referred  to  on  pp.  27,  28. 

III. — Cerebrospinal  Si/stem. 

The  nerves,  and  in  a  few  cases  the  spinal  cord,  are  stimulated 
from  their  alternate  elongation  and  shortening.  In  addition  to 
this  we  have  the  fact  that  every  voluntary  gymnastic  exercise 
calls  into  play  a  nervous  sensory  motor  circuit  (see  passive  move- 
ments, p.  39).  The  sensory  portion  is  composed  of  the  atferent 
nerves  (chiefly  those  of  the  muscles)  in  the  lower,  and  to  a  less 
extent  the  upper,  neuron ;    the  motor  portion  of  the  circuit  is 


'  "  De  quelques  variations  de  la  riohesse  globulaire  cliez  I'homme  sain,"  in 
Ccnnptes  rend,  de  la  Soc.  de  Biol.,  stance  du  Oct.  31,  1874,  and  in  Oaz.  Mid.  de  Paris, 
1874,  p.  573,  &c. 

-  "  Neue  Untersuchungen  iiber  BlutverSnderungeu  nach  thermisclieu  EingriSeu," 
Centralbl.  fiir  Klin.  Med.,  1893,  vol.  xiv.,  pp.  1017-1022. 

=  "  Preliminary  Note  on  the  Kffect  of  Massage  on  the  Blood  Count,''  in  Med. 
Neivs,  Philad.,  1893,  p.  715  ;  "  Notes  on  the  Effect  of  Massage  on  the  Blood  Count," 
in  College  of  Physicians,  Philad.,  1893,  third  series,  vol.  xv.,  pp.  240-'242  ;  "Effect 
of  Massage  on  the  Number  and  Haemoglobin  Value  of  the  Red  Blood  Cells,"  in 
American  Journal  of  the  Med.  Scie7ices,  Philad.,  1874,  new  series,  vol.  cvii.,  pp.  502- 
515;  "Uber  die  Wirkung  der  Massage  auf  die  Blutverschaffenheit,"  Pester  Med. 
Chir.  Presse,  1894,  No.  15. 

^  "  Hyperglobulie  iustantauee  par  stimulation  peripherique  ;  consequences,"  in 
Compt.  rend,  de  V Academic  des  Sciences,  1895,  tome  ii.,  No.  vi.,  p.  314. 

^ "  The  Blood  and  Blood  Pressure,"  1901,  pp.  45,  &c. 

""The  Effect  of  Exercise  on  the  Htemoglobin  with  Reference  to  the  value  of 
Rest  in  the  Treatment  of  Anaemia,"  in  British  Medical  Journal,  June  25,  1898. 

■  "  On  the  Physiological  Factors  involved  in  the  Causation  of  Dropsy,"  Lancet, 
May  9,  1896,  &c. 

"  "  Die  Aufuahme  der  Lymphe  durch  die  Sehnen  und  Pascien  der  Skelet- 
muskeln,"  Arb.  a.  d.  Phys.  Anst.  zu  Leipzig,  1871,  p.  51,  &c. 

"  "  Eine  Methode  um  grosse  Lymphmengeu  vom  lebenden  Hunde  zu  gewinnen," 
Arb.  a.  d.  Phys.  Anst.  zu  Leipzig,  1872,  p.  94. 

'°  "  Uber  die  Absonderung  der  Lymphe  im  Arme  des  Hundes,"  in  Arh.  a.  d. 
Phys.  Anst.  zu  Leipzig,  1873,  pp.  197,  &c. 


EFFECTS  OF  ACTIVE  AND  PASSIVE   MOVEMENTS        33 

composed  of  that  portion  of  the  hraiii  in  which  are  locahsed  the 
highest  mental  centres,  and  the  upper  and  lower  neurons,  with 
the  physiological  paths  of  continuity  between  them.  The 
improved  circulation  in  the  exercised  parts  will  bring  more 
nutrient  matter  to  the  peripheral  part  of  the  lower  neuron 
(perhaps  also  to  the  other  portions  of  the  motor  path),  thus 
stimulatmg  it. 

There  is,  in  fact,  an  educative  effect  on  the  nervous 
mechanism,  a  fact  recognised  very  early  by  the  pioneers  of  Ling's 
system,'  who  regarded  all  muscle  gymnastics  as  being  nerve 
gymnastics  as  well. 

Duplicate  movements  thus  help  to  train  the  individual  to 
place  his  body  better  under  the  influence  of  his  will.  By  their 
means  he  learns  to  specially  concentrate  his  energy  on  the 
muscles  called  into  action,  and  to  inhibit  all  others  from  working. 
Thus  an  education  of  the  muscular  sense,  powers  of  inhibition, 
and  also  of  the  sense  of  coordination  ensues. 

There  is,  in  addition,  an  effect  on  the  moral  and  mental 
faculties;  this  has  been  discussed,  amongst  others,  by  Hartelius.- 

TV. —Heart. 

In  ordinary  life,  any  exerting  movement  tends  to  accelerate 
the  cardiac  action  in  consequence  of  temporary  increased  peri- 
pheral resistance,  due  to  pressure  on  the  vessels  by  both  the 
muscles  acting  on  the  joint  moved  and  those  which  fix  the  joints 
above  and  below  it.  The  accompanying  tendency  to  hold  the 
breath  and  thereby  increase  the  intrabronchial  pressure  (Sommer- 
brodt's'  reflex),  also  acts  in  exciting  the  heart. 

But  with  properly  arranged  duplicate  movements,  given  so 
as  to  successively  exercise  the  various  peripheral  parts  of  the 
body,  the  action  of  the  patient's  fixators  is  eliminated,  and  in 
consequence  the  patient  is  enabled  to  concentrate  more  energy 
on  the    group    of    muscles    under    treatment.       And    in    medical 

'  Cf.  P.  H.  Ling,  "  Gymnastikens  AUmiiana  Grunder  "  {183i),  1810,  pp.  151,  &o. 
Georgii,  "  Kin&itherapie,"  1847  ;  "  Kinetic  Jottings,"  1880,  pp.  36,  38,  45,  47,  57,  &c. 
Hj.  Ling,  "Porkortad  Ofversigt  af  AUmiin  Riirelselara,"  1880,  pp.  51,  53,  and  liis 
preface  to  Branting's  "  Elterlemnade  Skrifter,"  1882,  pp.  xviii.  et  seq. 

-  "  Kroppsrorelsers  inflytande  p.i  det  andliga  lifvet,"  in  Tidskrift  i  Gymnastik, 
vol  i.,  1879,  pp.  688-690.    "Liirobok  i  Sjukgymnastik,"  1888,  p.  140, 1892,  pp.  138, 139. 

'  "  tjber  eine  bisher  nicht  gekannte  wichtige  Eiurichtuug  des  menschlicheu 
Orgaoismus,"  1882. 

3 


34     ELEMENTS   OF  KELLGREN'S   MANUAL    TREATMENT 

gymnastics  a  patient  is  never  allowed  to  forcibly  hold  the  breath 
during  the  execution  of  any  movement  (see  p.  124).  After 
the  conclusion  of  the  movements  there  will  be  a  fall  in  the  general 
arterial  resistance.  • 

Therefore,  not  only  are  practically  ehminated  all  the  factors 
which,  acting  together,  increase  the  cardiac  action,  but  there  is 
also  introduced  into  the  blood  vascular  system  a  kind  of  peri- 
pheral pump  which  relieves  the  heart  of  part  of  its  work. 

Even  if  a  slight  increase  in  the  cardiac  work  results  during 
the  giving  of  the  movements,  this  acts  beneficially,  unless  in 
cases  of  extreme  weakness  of  the  heart.  This  is  because  the 
heart  has  (excepting  in  the  case  just  mentioned)  a  certain  amount 
of  reserve  power  which  is  thus  partially  called  into  play.  The 
heart,  therefore,  having  received  the  impulse  to  better  action  in 
consequence  of  increased  resistance,  is  enabled  to  act  better  still 
when  the  latter  is  reduced  below  its  original  amount. 

V. — Muscles. 

As  already  stated  on  p.  11  the  resistance  offered  to  the 
patient's  efforts  is  so  graduated  as  to  permit  of  the  maximum 
effect  desirable  being  obtained.  It  is  also  known  that  the  greater 
the  force  (within  physiological  limit)  opposed  to  a  contracting 
muscle,  the  more  will  that  muscle  try  to  overcome  it. 

In  this  way  is  obtained  the  maximum  of  increased  growth  and 
activity ;  there  is  increase  in  the  size  of  the  individual  fibres, 
and,  consequently,  of  the  muscle  as  a  whole,  and  increase  in  its 
active  constituents  ;  the  muscle  works  with  greater  speed,  cer- 
tainty and  force ;  its  tonicity  during  rest  is  in  a  better  condition 
and  its  attachments  to  bones,  &c.,  become  stronger. 

Changes  in  the  circulation  in  active  muscles  during  and  after 
contraction  have  been  already  referred  to  on  pp.  28,  &c. 

The  same  muscles  are  exercised  if  a  movement  is  first  executed 
concentrically  and  then  the  reverse  movement  excentrically ; 
antagonistic  groups  of  muscles  are  exercised  if  the  same  move- 
ment is  executed  first  concentrically  and  then  excentrically.  In 
the  case  of  a  duplicate  concentric  exercise  the  active  muscles  are 
shortened  and  their  antagonists  are  passively  elongated.'  In  the 
case  of  a  duplicate  excentric  exercise  the  former  are  elongated 

'  See  Hj.  Ling,  "  De  Forsta  Begreppen  a£  Rurelselilran,"  18G6,  p.  218. 


EFFECTS  OF  ACTIVE  AND  PASSIVE  MOVEMENTS       35 

and  the  latter  passively  shortened.  Thus  the  muscular  force  is 
greatest  at  the  beginning  and  least  at  the  end  in  the  case  of  a 
concentric  movement ;  the  reverse,  hovi^ever,  holds  good  in  the 
case  of  an  excentric  movement. 

Every  active  movement,  whether  given  with  or  without  resist- 
ance, has  a  standard  rate  of  execution,  which  is  such  that  the 
maximum  physiological  effect  may  be  produced.  (This  rate  is,  of 
course,  modified  to  suit  different  patients  and  the  nature  of  the 
malady  under  treatment.) 

An  increase  in  muscle  energy  implies  the  using  up  of  more 
sugar ;  thus  an  increase  would  result  in  the  glycogenic  function 
of  the  liver. 

VI. — Joints  and  Ligaments. 

The  joints  are  exercised,  rendered  more  supple  and  become 
stronger ;  the  latter  is  due  to  the  strengthening  of  the  ligaments 
and  muscles  that  surround  them.  In  most  cases  elasticity  in  the 
ligaments  acts  as  a  substitute  for  muscle  power,  and  in  nearly  all 
joints  the  tendons  themselves  act  as  ligaments.  In  consequence 
of  the  vaso-dilatation  the  nutrition  of  the  bones  and  ligaments 
is  promoted. 

The  final  result  of  duplicate  movements  on  joints  is  to  restore 
their  normal  articular  function,  and  in  some  cases  such  movements 
can  be  used  to  increase  the  amount  of  synovial  fluid  in  conditions 
of  insufficiency  thereof;  in  other  cases,  however,  they  can  be 
used  to  promote  the  absorption  of  pathological  excess.  Duplicate 
movements  also  tend  to  break  down  and  remove  any  stiffness, 
adhesion  or  deposits  (gouty  or  otherwise)  in  the  joint  or  in  the 
periarticular  tissues. 

VII. — Bespira  tion . 
Duplicate  movements,  properly  arranged,  tend  to  make 
respiration  deeper  and  slower  after  their  execution.  This  is 
caused  by :  {a)  The  strict  enforcement  of  the  rule  that  deep  and 
full  respiration  is  to  take  place  during  all  such  movements. 
(h)  Stimulation  of  the  respiratory  centre  by  the  metabolites. 

VIII. — The  Metabolism  of  the  Body  as  a  Whole. 
This  tends  to  be  increased  with  beneficial  effect,  and  thus  the 
demand  for  more  nutrient  matter  increases.     There  is  in  conse- 
quence an  increase  in  the  excretions. 


36     ELEMENTS  OF    KELLGREN'S    MANUAL    TREATMENT 

Some  of  the  above  effects  are  immediate,  coming  either 
daring  the  performance  of  the  movement  or  just  after  it.  Others, 
on  the  contrary,  for  example,  the  educative  effect  on  the  brain, 
may  not  be  apparent  until  a  number  of  days,  or  even  weeks,  has 
elapsed. 

Duplicate  movements  have  many  distinct  advantages  over 
purely  active  ones,  as  follows  : — 

(1)  Groups  of  muscles,  or  even  individual  muscles  (in  rare 
cases  actually  part  of  one  muscle)  can  be  isolated  by  eliminating 
the  co-action  of  their  antagonists,  and  also  of  the  muscles  that 
fix  the  joints  above  and  below  the  one  that  is  being  exercised. 
Thus  the  patient  is  enabled  to  concentrate  all  his  available  energy 
on  that  group  or  individual  muscle. 

(2)  Contraction  can  be  brought  about  very  early  in  apparently 
totally  paralysed  muscles,  and  some  patients  can  perform  dupli- 
cate excentric  movements  sooner  than  they  could  the  corre- 
sponding purely  active  ones  in  which  the  same  muscles  would 
be  called  into  action. 

(3)  The  work  done  by  the  patient  can  be  graduated  to  any 
amount  desirable. 

(4)  By  means  of  isolation  it  is  possible  to  draw  blood  to  or 
from  almost  any  part  of  the  body  desired. 

(5)  Time  is  gained  by  concentrating  the  maximum  effect  into 
the  minimum  duration. 

(6)  As  the  traction,  by  separating  the  opposing  surfaces  of 
a  joint,  to  a  great  extent  eliminates  pain  due  to  interarticular 
friction,  it  is  found  that  patients  can  often  be  enabled  to  perform 
strong  duplicate  movements,  concentric  as  well  as  excentric, 
whereas  they  could  not  or  would  not  perform  the  corresponding 
purely  active  ones  because  of  the  great  pain  that  would  inevitably 
arise. 

(7)  There  is  obtained  the  extra  stimulatory  effect  of  the 
traction  applied. 

Apart  from  their  therapeutic  value  in  the  treatment  of 
diseases,  duplicate  movements  are  of  great  interest  from  a  purely 
anatomical  point  of  view.  By  means  of  the  fact  that  the 
maximum  amount  of  work  is  obtained  from  the  muscles,  and 
also  from  the  circumstance  that  the  latter  can  be  so  readily 
eliminated  and  their  action  isolated,  duplicate  movements  afford 
one    of   the    best    methods    for    studying    muscular    actions    and 


EFFECTS  OF  ACTIVE  AND  PASSIVE   MOVEMENTS       37 

relative  strengths.  Therefore  duphcate  movements  are  invaUiable 
as  a  diagnostic  method  for  determining  the  presence  or  absence 
of  paresis  or  paralysis.' 

It  is  necessary  to  refer  in  greater  detail  to  No.  (1)  above. 
In  the  case  of  all  active  exercises  there  must  be  a  fixed  point  for 
the  movement  to  start  from — i.e.,  the  patient  must  fix  his  trunk 
in  arm  movements,  his  lower  leg  in  foot  movements,  and  so  on, 
using  in  order  to  effect  this  his  own  muscles  ;  the  latter,  however, 
can  be  thrown  out  of  action  by  fixing  the  part  in  question  for 
him.  For  example,  if  a  patient  be  asked  to  abduct  his  arm  to 
a  right  angle,  and  keeping  it  there  to  alternately  flex  and  extend 
his  wrist  with  resistance  applied  by  the  assistant  over  the  palm 
and  corresponding  dorsal  aspect  of  the  metacarpus  respectively, 
it  will  be  found  that  he  can  exert  very  little  force  in  the  execution 
of  the  movement,  as  any  greater  effort  would  prevent  him  from 
keeping  the  elbow  and  shoulder  joints  immovable.  If,  however, 
his  upper  arm  be  fixed,  he  will  be  able  to  exert  much  more  force 
in  executmg  the  movement,  having  only  to  fix  his  elbow  joint. 
If,  finally,  his  forearm  be  fixed,  it  will  be  possible  to  obtain  the 
maximum  amount  of  work  from  the  flexors  and  extensors  of  his 
wrist,  for  he  is  then  able  to  concentrate  without  any  waste  the 
whole  of  his  available  energy  on  these  muscles. 

The  mechanical  conditions  to  he  dealt  with  in  all  duplicate 
movements  are  those  peculiar  to  a  lever.  The  fulcrum  of  the 
lever  is  the  joint  at  which  the  movement  takes  place,  and  the 
forces  acting  are,  firstly,  the  patient's  muscles,  and,  secondly,  the 
opposing  muscles  of  the  assistant.  The  point  of  application  of 
the  assistant's  force  should  therefore,  under  ordinary  circum- 
stances, be  removed  as  far  as  possible  from  the  joint  that  is  to 
be  moved.  By  means  of  such  increased  leverage  he  lessens  his 
own  exertions,  and  is  consequently  better  enabled  to  modify  his 
powers  to  suit  the  phase  of  the  movement,  and  also  obtains  a 
better  command  over  the  part  moved. 

The  contrary,  however,  must  be  said  respecting  cases  in  which 
it  is  desired  to  have  absolute  control  of  only  one  joint,  such  as  in 
paralysis,  synovitis,  &c.  In  such  conditions  the  outside  force  is 
often  advantageously  applied  as  near  as  possible  to  the  insertion 
of  the  muscle   it  is  attempted   to  stimulate,  because   thus  the 

'  See  part  ii.,  chap.  i. 


38     ELEMENTS   OF   KELLGREN'S   MANUAL   TREATMENT 

proportion  of  the  patient's  force  as  compared  with  the  assistant's 
becomes  relatively  greater.  By  these  means  the  patient  is  made 
conscious  as  early  as  possible  of  possessing  the  power  of  volun- 
tary movement.  This  method  is  also  of  importance,  because 
there  is  more  complete  isolation  of  the  muscle  in  question,  and 
because  the  effect  of  the  traction  applied  is  wholly  transmitted 
to  the  joint  exercised,  instead  of  being  expended  in  part  on 
other  joints  below  it. 


(C) — Physiological  Effect  of  Passive  Movements. 

I. — Passive  movements  at  joints. — With  all  these,  where 
possible,  traction  of  the  part  is  maintained  just  as  in  duplicate 
movements.  The  effects  of  this  traction  have  been  considered 
already.  In  addition  there  are  the  effects  of  the  movement  itself, 
which  vary  very  greatly  according  to  the  manner  in  which  it  is 
given,  as  follows  :  — 

(1)  When  the  movements  are  given  energetically  and  through 
a  large  radius.  The  effects  are  on  the  same  lines  as  those  induced 
by  duplicate  movements,  only,  of  course,  not  so  marked,  as 
follows : — 

(a)  Stimulation  of  the  muscles  from  their  alternate  elongation 
and  shortening. 

(6)  Vaso-dilatation  and  increase  in  the  amount  of  blood  in 
the  part  exercised  in  consequence  of  general  stimulation. 

(c)  Furthering  of  the  circulation  of  the  blood. 

(fZ)  An  effect  on  the  blood  itself  (see  p.  31). 

(e)  Increased  production  of  lymph  and  furthering  of  its  flow, 
facts  which,  though  known  practically  to  and  clinically  demon- 
strated by  the  Ling  school  many  years  ago,'  were  not  actually 
shown  by  experiment  until  Genersich,^  Lesser,"  and  Paschutin^ 


'  See  Georgii,  "  Kin^sitherapie,"  1847,  p.  34.  Rothstein,  "Die  Gymnastik  uach 
dem  System  des  Sohwedischeu  Gymnasiarchen  P.  H.  Liug,"  1847.  Richter, 
"  Organon  der  Physiologischen  Therapie,"  1850,  p.  209.  Neumann,  "Die  Heil- 
gymnastik,"  1852,  pp.  34,  &c.  Eulenburg,  "  Die  Schwedische  Hcilgymuastik,"  1853, 
pp.  99,  123.  Hj.  Ling,  "  De  Porsta  Bcgreppen  af  Rorelseliirau,"  18G6,  p.  139.  Loven, 
"  Om  Viifnadssaften  i  dess  foi'haUande  till  Blod  och  Lymphkarl  "  iu  Hygiea,  Feb., 
1875,  pp.  80-93.  Hartelius,  "  Om  ResorbtionsriJrelsers  Uppkomst  och  Verkan,' 
in  Tidskrift  i  Gymnastik,  1876,  part  7,  pp.  253,  &c.  Hj.  Ling  iu  Branting's 
"  Efterlemnade  Skrifter,"  1882,  pp.  xxix. ,  xxx. 

-  Op.  cit.,  see  p.  32. 


EFFECTS  OF  ACTIVE  AND   PASSIVE   MOVEMENTS 


39 


did  so  in  Ludwig's  laboratory.  (See  also  the  researches  of 
Ludwig  and  Schweigger-Seidel'  and  Lassar.') 

{/)  Increased  suppleness  of  joints ;  while  any  adhesions, 
stiffness,  deposits,  &c.,  will  tend  to  be  overcome  and  dissipated. 

(g)  Stimulation  of  the  nerves  from  alternate  elongation  and 
shortening,  and  from  the  improvement  in  the  circulation  in  the 
blood.  The  elongation  of  the  nerves  through  elongation  of  the 
muscles  stimulates  the  reflex  spinal  arc,  and  this  is  further 
reinforced  through  shortening  of  the  antagonists,  as  shown  by 
Sherrington.'*  Passive  movements  thus  stimulate  the  afferent 
nerves  (chiefly  those  of  the  muscles)  and  the  efferent  nerves  of 
the  lower  neuron,  possibly,  also,  those  of  the  upper  neuron. 

(/i)  An  increased  feeling  of  warmth  and  an  actual  rise  in  the 
temperature  of  the  part. 

(2)  When  the  movements  are  given  slowly  through  a  large 
radius.  The  effects  are  in  kind  the  same  as  before,  but  the 
slowness  of  the  movement  gives  rise  to  less  stimulation  of  the 
nerves  and  muscles,  and  the  amount  of  blood  flowing  to  the  latter 
is  not  increased  to  so  marked  a  degree. 

(3}  When  the  movements  are  given  gently  througli  a  small 
radius. 

The  effect  on  the  muscles  and  nerves  is  very  small.  In  cases 
where  there  is  a  tendency  to,  or  an  actual  presence  of,  a  hyper- 
semic  or  congested  state  in  the  part  manipulated,  the  latter  will 
improve,  for  the  venous  return  will  proceed  faster  than  the 
arterial  flow.     This  is  because :  — 

(a)  There  is  practically  no  vaso-dilatation,  the  stimulatory 
effects  being  very  small. 

(b)  The  veins,  lying  as  they  do  more  superficially,  are  elongated 
and  shortened  more  than  are  the  deeper-lying  arteries,  as  the 
movement  stretches  and  relaxes  the  superficial  parts  to  a  greater 
extent  than  the  more  central  ones  of  the  part  in  question. 

(c)  The  number  and  size  of  the  veins  is  usually  greater  than 
that  of  the  arteries  ;  in  the  body,  as  a  whole,  the  ratio  of  their 
respective  capacities  is  about  9  :  4. 

The    lymphatic    return    is    likewise    promoted    (see    p.    3'2), 

'  Op.  cit.,  see  p.  28. 

^  "  tjber  CEdem  und  Lymphstrom  bei  der  Eutziiudung,"  in  Vircliow's  Aickiv., 
vol.  Ixix.,  1877,  pp.  516,  &c. 

» In  Sohafer's  "Textbook  of  Physiology,"  vol.  ii.,  1900,  p.  873. 


40     ELEMENTS   OF   KELLGREN'S    MANUAL   TREATMENT 

joints  are  rendered  more  supple,  and  stiffness,  adhesions,  6:c.,  if 
present,  tend  to  be  removed.  Any  stimulatory  effects  are  practi- 
cally entirely  due  to  the  traction  applied. 

Between  the  extremes  of  the  three  above  classes  there  are,  of 
course,  an  infinite  nnmber  of  intermediate  grades,  and  the  effects 
vary  accordingly. 

II. — Passive  Movemcids  irhere  no  Joint  is  Moved.  —  The 
physiological  effects  of  such  manipulations  as  vibrations,  nerve 
frictions,  &c..  will  be  discussed  when  the  individual  movements 
are  considered. 


CHAPTER  y. 

GYMNASTIC    MOVEMENTS. 

I  SHALL  now  proceed  to  describe  the  more  important 
gymnastic  movements  as  they  are  performed  by  Henrik  Kellgren. 
The  arrangement  of  these  in  an  orderly  series  is  a  matter  of  no 
Uttle  difficult}'.  The  ideal  classification  would  systematise  the 
movements  in  accordance  with  their  physiological  effects ;  but 
such  an  order  would,  unfortunately,  involve  too  great  complexity 
in  other  directions,  as  will  readily  be  perceived;  for  example,  a 
movement  devised  to  especially  benefit  the  respiratory  organs 
also  acts  on  the  circulation  ;  a  movement  for  the  circulation  also 
acts  on  the  nervous  system  ;  and  so  on.  Neither  can  the  move- 
ments be  divided  into  two  hard  and  fast  groups  of  "active"  and 
"  passive  "  ;  some  of  them  may  be  administered  actively  to  suit 
one  case,  and  passively  to  suit  another ;  passive  manipulations 
ma}'  be  applied  to  a  patient  while  the  latter  is  simultaneously 
performing  an  active  movement ;  and  so  on. 

I  have  determined  to  arrange  all  the  movements  under  the 
following  heads  : — 

Flexion  and  extension  (includmg  falling  and  ringing). 

Abduction  and  adduction. 

Rotation  (turning). 

Pronation  and  supination. 

Inversion  and  eversion. 

Circumduction. 

Traction. 

(Arm-)  carrying. 

Drawing. 

Expansion. 

Lifting. 

Vibration  and  shaknig. 

Friction. 

Hacking,  clapping  and  beating. 

Stroking. 


42     ELEMENTS   OF   KELLGREN'S    MANUAL   TREATMENT 

Kneading. 
Pressing. 

Various  other  movements  which  do  not  fall  nnder  an}'  of  the 
previous  headings. 

Special  manipulations  of  various  organs  and  regions. 

Tcrmiitology.^ 

The  terms  given  above  are  in  themselves  occasionally 
ambiguous,  but  they  have  been  in  use  so  long  that  to  change 
them  vifould  only  cause  confusion. 

The  word  "  double  "  (sometimes  abbreviated  to  "  2  ")  placed 
before  an  arm  (or  leg)  movement,  means  that  the  movement 
involves  both  arms  (or  both  legs)  simultaneously.  Whenever 
it  is  desired  to  exercise  only  one  arm  or  leg,  or  to  perform  a 
movement  only  to  one  side  with  the  head  or  trunk,  the  word 
right  or  left  precisely  specifies  which.  When  the  terms 
"  double,"  "  right"  or  "  left  "  are  omitted  the  movement  is  first 
to  be  accomplished  with  one  leg,  one  arm,  or  to  one  side  with 
the  head  or  trunk,  as  the  case  may  be,  and  then  with  the  other, 
or  on  the  other  side.  With  certain  movements  the  word  "  alter- 
nate "  is  used  to  convey  the  same  meaning. 

PA  means  "  patient  active,"  i.e.,  a  purelj^  active  movement  is 
to  be  executed.  In  the  case  of  a  duplicate  movement,  AE 
(assistant  resisting),  or  PE  (patient  resisting),  denotes  whether 
it  is  to  be  concentric  or  excentric.  PP  means  "  patient  passive" 
— i.e.,  a  passive  movement  is  to  be  administered.  If  two  such 
abbreviations  be  given  together,  say  AE,  PE,  the  first  half  of 
the  movement  is  to  take  place  concentrically,  the  second  half 
excentrically. 

In  specifying  the  formula  for  any  movement  the  following 
order  is  maintained : — 

(1)  The  name  of  the  initial  position. 

(2)  The  name  of  the  part  or  parts  of  the  body  to  be  moved, 
with  the  prefix  "  double,"  "  right  "  or  "left,"  if  necessary,  inserted 
before  that  part  (or  each  part  if  there  be  more  than  one). 

(3)  The  name  or  description  of  the  actual  movement  or  move- 
ments to  be  executed. 

'  The  terms  are,  slightly  modified,  those  of  Branting,  who  devised  a  series  for  the 
exercises  themselves  as  well  as  for  the  positions  {see  p.  16). 


GYMNASTIC  MOVEMENTS  43 

(4)  Whether  the  movemeuts  be  PA,  AE,  PK  or  PP,  or  a 
combination  of  two  of  these. 

Whenever  both  purely  active  and  duphcate  forms  of  an 
exercise  exist,  the  latter  only  will  be  described  ;  the  reader  will 
be  able  without  difficulty  to  deduce  the  modus  operandi  and 
effect  of  the  former. 

In  the  following  descriptions  it  is  to  be  understood  that,  with 
the  exception  of  the  part  actually  moved,  the  body  is  to  be  kept 
strictly  in  the  same  (initial)  position  throughout.  When  discuss- 
ing the  question  of  what  muscles  are  called  into  action,  it  will 
be  unnecessary  to  consider  those  which  are  only  used  to  fix  the 
various  joints,  above  or  below  (or  both)  the  one  actually  moved, 
unless  they  happen  to  call  for  special  mention.  The  effects  of 
a  particular  movement  having  been  described,  and  any  special 
mechanism  or  anatomical  point  of  interest  having  been  pointed 
out,  such  details  will  not  be  repeated  in  connection  with  any 
other  exercises  characterised  by  the  same  features. 

As  this  work  does  not  aim  at  being  a  handbook  for  beginners, 
but  is  an  attempt  at  a  scientific  interpretation  of  Kellgren's 
manual  treatment,  many  points  concerning  the  mere  technique, 
such  as  variations  in  the  positions  assumed  by  the  assistant, 
different  methods  of  grasping  the  parts  to  be  moved,  &c.,  will 
be  neglected.  Similarly  many  details  as  to  differences  between 
Kellgren's  methods  on  the  one  hand,  and  Wide's  on  the  other, 
will  also  be  omitted,  space  being  only  reserved  for  a  few  of  the 
more  important  ones. 

General  Directions. 

All  active  movements  are  to  be  carried  out  slowly  and  evenly, 
and  the  minds  of  both  patient  and  assistant  must  be  concentrated 
upon  them ;  automatic  movements  are  useless.  All  exercises, 
whether  active  or  passive,  must  be  modified  to  suit  each  patient, 
and  yet  further  to  suit  the  daily  variations  of  each  patient's  health. 
This  is  commonly  called  individualising  the  exercise. 

Whether  a  purely  active  or  a  duplicate  movement  is  to  be 
executed,  the  patient  should  stretch  himself  well,  bring  his  chest 
out,  and  let  respiration  be  as  free  as  possible.  (See  expansion 
pp.  124,  &c.).  With  every  movement  involving  increase  and 
decrease  in  the  size  of  the  chest,  the  patient  should  take  a  deep 


44    i-:lements  of  kellgren's  manual  treatment 

inspiration  durinf^  the  former,  and  a  deep  expiration  durinff  the 
latter.  After  the  completion  of  each  exercise  a  deep  respiration 
must  be  taken. 

Active  movements  are  as  a  rule  executed  three  times;  if 
performed  properly,  this  number  will  generally  be  quite  sufficient 
to  produce  the  maximum  effect  within  the  physiological  limit. 
In  accordance  with  Ling's  fundamental  principle  of  equilateral 
harmonious  development,  all  exercises  involving  only  one  limb  or 
one  side  of  the  head  or  trunk  are  repeated  in  the  same  manner  an 
equal  number  of  times  on  the  other  side,  unless  contraindicated 
by  the  presence  of  unilateral  pathological  conditions. 

All  movements  at  joints,  whether  active  or  passive,  are  to 
be  executed  through  the  greatest  range  possible,  unless  contra- 
indications (such  as  acute  inflammations,  &c.)  exist ;  or,  as  in  a 
few  cases,  when  the  exercise  is  intended  to  be  accomplished  only 
in  part. 

As  the  muscular  action  in  duplicate  concentric  movements  is 
strongest  at  the  beginning,  but  weakest  at  the  end  (the  reverse 
holding  good  for  duplicate  excentric  movements),  it  is  often 
advantageous  at  the  very  termination  of  a  concentric  exercise  to 
assist  the  patient's  efforts  a  little ;  because,  although  the  patient 
could  not,  unaided,  continue  the  movement  as  far  as  the  point  to 
which  the  assistant's  help  can  bring  it,  yet  he  can  perform  it 
excentrically  from  that  point — i.e.,  he  can  offer  resistance  at  once 
when  the  reverse  movement  is  executed.' 


'  Side  lying  leg  abduction  AR,  adduction  PR,  is  a  very  good  example  of  where 
this  can  be  done  (see  p.  94). 


GYMNASTIC  MOVEMENTS  45 

FLEXION    AND    EXTENSION. 
I.— Flexion  and   Extension  of  the   Upper  Extremity. 

(1)    Of  the    Shoulder-joint. 

Mechanism  of  these  movements. — Anatom}'  text-books  as  a 
whole  ignore  the  fact  that  flexion  and  extension  of  the  shoulder 
joint  are  accompanied  by  co-movements  of  the  scapula  which  are 
similar  to  those  that  occur  during  aV)duction  and  adduction  of 
that  joint. 

Suppose  an  individual  to  be  sitting  or  standing  with  his  arm 
hanging  vertically  downwards.  What  ordinarily  takes  place  when 
he  flexes  his  shoulder-joint  is  as  follows : — The  first  half  of  the 
movement  up  to  the  horizontal  is  accompanied  by  rotation  of 
the  scapula  on  its  own  long  axis,  together  with  movement  of  the 
whole  bone  en  masse  round  the  side  of  the  chest ;  then,  after  the 
humerus  has  passed  the  horizontal,  this  rotation  becomes  less 
and  less,  and  almost  disappears  when  the  final  stage  of  the 
movement  up  to  the  vertical  is  reached.  During  the  reverse 
movements  of  the  humerus  the  reverse  obtains  (as  regards  the 
scapula). 

When,  however,  the  individual  executes  a  gymnastic  exercise 
comprising  such  flexion  of  the  shoulder-joint  (during  which  the 
shoulders  are  to  be  kept  drawn  inwards  and  backwards)  the 
sequence  of  events  is  difl'erent.  During  the  first  half  of  the 
flexion  the  scapula  practically  remains  fixed,  neither  rotating  on 
its  own  long  axis  nor  moving  en  masse  round  the  wall  of  the 
chest.  The  scapula  commences  to  rotate  only  when  the  hori- 
zontal has  been  passed,  and  this  rotation  is  contmued  until  the 
final  stage  of  the  movement,  when  it  practically  disappears. 
During  the  reverse  movements  of  the  humerus  the  reverse 
obtains  (as  regards  the  scapula). 

The  reason  for  keeping  the  shoulders  drawn  backwards  and 
inwards  when  executing  gymnastic  movements  is  that  this 
position  enables  the  chest  to  be  expanded.  In  consequence  of 
the  fixation  of  the  scapula,  the  coracoid  process  and  hmnerus  are 
kept  as  far  back  as  possible,  and  therefore  any  contraction  of  the 
pectoral  muscles   only  results  in   approximating  the  ribs  to   the 


46     ELEMENTS    OF   KELLGREN'S    MANUAL   TREATMENT 

scapula ;  in  other  words,  the  ribs  are  Hfted  upwards  and  a  chest 
expansion  results.  If  the  scapula?  were  not  kept  fixed  in  the 
above  waj%  then  the  pectorals,  by  drawing  them  forward,  would 
bring  about  round  shoulders. 

If  instead  of  stopping  at  the  vertical  during  the  reverse  move- 
ment, the  arm  be  extended  backwards  during  either  of  the 
foregoing  exercises,  the  range  of  the  movement  is  increased  by 
about  another  50°,  making  the  total  range  230°.' 

Another  point  that  seems  to  have  escaped  observation  is  that 
at  the  close  of  the  flexion,  i.e.,  when  the  humerus  lies  vertical, 
practically  the  same  muscles  must  be  acting  as  those  which  main- 
tain the  humerus  vertical  after  abduction  through  180°.- 

Flexion  and  extension  of  the  shoulder-joint  is  found  in  the 
following  exercises : — 

Standing  Double  Arm  Raising  Forwards   and   Upwards,  PA. 

The  patient  assumes  the  standing  position  and  then  raises 
his  arms,  which  are  to  be  kept  parallel  the  whole  time,  from 
the  initial  hanging  downwards  to  the  reach  position  (fig.  58, 
p.  117),  where  the  movement  may  stop;  or  it  may  be  continued 
until  the  arms  are  in  stretch  position  (fig.  7,  p.  18)  and  the 
chest  well  lifted  up,  a  deep  inspiration  being  taken  coincidently. 
The  reverse  movement  may  then  be  executed,  or  instead  the 
arms  may  be  adducted,  a  deep  expiration  being  taken  while 
doing  so  (see  p.  131). 

Physiological  effect.^ — The  muscles  that  act  as  fixators  of  the 
joints  above  and  below  the  shoulder-joint,  and  also  those  which 
perform  the  movement  at  the  last,  have  an  extra  amount  of  blood 
sent  to  them  in  consequence  of  their  activity. 

No  movement  of  the  shoulder-joint  can  be  executed  without 
contracting  most  of  the  muscles  of  the  shoulder-girdle  in  order  to 
keep  the  latter  steady,  or  to  move  it  if  it  have  a  relative  co-motion 
of  its  own.  The  latter  movement  may  be  one  either  of  the 
scapula,  the  clavicle,  or  both.  All  movements  of  the  humerus 
likewise  have  to  be  executed  with  fixation  or  co-movement  of  the 

'  Cf.  Hj.  Ling,  "  De  Fiirsta  Begreppeu  af  Eorelseliiran,"  18G6,  p.  204. 

-Cf.  Neumann,  "Das  Muskelleben  des  Mcuscheu  in  Beziehuug  au£  Heilgym- 
nastik  und  Turnen,"  1855,  pp.  1'24,  125. 

'  The  effects  of  all  active  and  passive  exercises  are  generally  more  marked  in 
pathological  than  in  normal  conditions. 


GYMNASTIC  MOVEMENTS  47 

joints  below,  most  of  the  other  muscles  of  the  limb  being  thus 
involved,  unless  it  is  attempted  to  eliminate  their  action  by  means 
of  fixation  or  support. 

Thus  every  gymnastic  exercise  of  the  arms  which  entails 
movement  of  the  shoulder-joint  brings  about  an  increased  supply 
of  blood  to  all  the  muscles  of  the  shoulder-girdle  and  arm  that 
are  involved.  Practically  all  these  muscles  receive  their  arterial 
supply  from  the  subclavian  artery  and  its  ramifications  (excepting 
the  vertebral),  and  thus  the  blood  supply  to  the  brain  (which  goes 
via  the  common  carotid  and  vertebral)  will  be  diminished. 

Effect  of  this  movement  on  the  radial  pulse,  on  the  volume  of 
blood  in  the  arm,  and  the  heart  beat  in  normal  persons.  When 
the  arm  is  hanging  vertically  downwards,  the  arteries  and  veins 
contain  more  blood,  due  to  the  action  of  gravity,  and  the  sphyg- 
mogram  shows  a  marked  dicrotic  wave ;  when  the  arm  is 
stretched  vertically  upwards,  the  arteries  contract,  the  dicrotism 
markedly  diminishes,  and  an  anacrotic  wave  manifests  itself,  the 
latter  persisting  for  at  least  ten  minutes  after  the  completion 
of  the  movement.  (Urlich/  Meuli,-  v.  Kries,'  v.  Frey^ ;  Cf.  Hill 
Baynard  and  Sequeira.^)  The  volume  of  the  hand  when  raised 
from  the  vertically  hanging  down  to  the  stretch  position, 
diminishes  1'2  cc.  ;  that  of  the  hand,  forearm  and  lower  third 
of  the  upper  arm  when  domg  the  same  movement  is  reduced  by 
30  cc.  (Wolff '^).  Elevation  of  both  arms  slightly  reduces  the 
rate  of  the  cardiac  action  (Marey '). 

The  next  point  to  consider  is  the  effect  of  movement  of  the 
humerus,  scapula,  and  clavicle  on  the  venous  return  from  the  head 
and  arm.  Apart  from  the  promotion  of  the  flow  by  the  muscular 
movement,  certain  special  anatomical  mechanisms  exist  which 
assist  the  process  (see  p.  80). 

'  "  Uber  die  Elasticitiits-Verhiiltuisso  der  Arterien  bei  vorticaler  Elevation,"  in 
Langenbeck's  Archiv  f.  Klin.  Chir.,  vol.  xxvi.,  1881,  pp.  1-8. 

■^  "  Die  Veranderungeu  von  Pals  uud  Temperatur  bai  elevirten  Gliedern,"  Thesis, 
1832. 

3  "  Studien  zur  Pulslehre,"  1892,  pp.  106,  &o. 

'  "  Die  Untei'sucUungen  des  Pulses  und  ihre  Ergebnisse  in  gesunden  uud  krankea 
Zustandon,"  1892,  pp.  219,  &c. 

5  "The  Effect  of  Venous  Pressure  on  tlie  Pulse,"  in  Journal  of  Physiology,  1897, 
vol.  xxi.,  p.  147,  &c. 

»  "  ijhir  Schwankungeu  der  BlutfiUlo  der  Extramitaten,"  in  Du  Bois  Reymond's 
Arch.,  1879,  p.  161. 

'  "Physiologie  medicale  de  la  circulatiou  du  sang,"  1863,  p.  214.  Cf.  also 
Georgii,  "  Kinetic  Jottings,"  18S0,  pp.  66,  67. 


48     ELEMENTS    OF    KELLGREN'S    MANUAL    TREATMENT 

(1)  The  axillai-y  vein. — Its  walls  are  attached  to  the  axillary 
fascia,  which  stretches  between  the  teres  major  and  latissimus 
dorsi  posteriorly,  and  the  pectoralis  major  anteriorly.  Con- 
traction in  these  muscles  causes  a  stretching  of  the  fascia,  which 
in  consequence  opens  up  the  vein  ;  subsequent  relaxation  of  these 
muscles  effects  the  reverse.  Thus  an  alternating  suction  and 
force  pump  is  established.     (Braune.') 

("2)  The  subclavian  vein. — "  This  vein  from  the  pectoralis 
minor  to  the  scalenus  anticus  rests  in  a  space  of  which  the 
walls  are  quite  exceptionally  moveable  and  capable  of  exerting 
a  very  powerful  suction  on  the  vein.  On  exposing  the  vein  by 
removing  a  portion  of  the  pectoralis  major  and  the  cellular  tissue 
above  the  clavicle  it  is  easily  demonstrated  that  by  means  of 
movements  of  the  arm  and  clavicle  the  walls  of  the  vein  are 
drawn  apart,  and  that  the  venous  trunk  itself  alternately  fills 
and  empties."     (Braune.^) 

(8)  Internal  jugular  vein. — A  similar  mechanism  to  the  above 
exists  in  regard  to  movements  of  the  sterno-mastoid,  as  the  walls 
of  the  vein  are  attached  to  the  fascia  covering  that  muscle 
(Herzog^;  cf.  Braune*).  (The  mechanism,  however,  does  not 
produce  its  effect  if  the  cervical  vertebrte  are  extended  backwards 
beyond  a  certain  limit,  See  p.  74.)  The  sterno-mastoids  are 
called  into  action  in  many  shoulder  movements  in  which  the 
clavicles  participate. 

Braune  also  pointed  out  that  just  about  the  sites  of  the  above- 
mentioned  mechanisms  there  are  many  more  venous  tributaries 
than  in  other  parts  of  the  vessels. 

From  the  above  it  is  obvious  that  all  active  arm  exercises, 
but  especially  those  in  which  there  exists  co-movement  of  the 
clavicle,  are  depletive  for  the  head.  The  same,  only  to  a  less 
extent,  holds  good  for  all  passive  movements  at  joints  in  which 
the  same  parts  are  involved.     In  consequence  of  this  depleting 

'  "Die  Oberschenkelvene  des  Menschen  iu  Anatomischer  u.  lOinischer  Bezic- 
hung,"  1873,  p.  9. 

-  ■'  Die  Oberschenkelvene  des  Menschen  in  Anatomischer  u.  Kliuischer  Bezie- 
bung,"  1873,  p.  9,  translated,  and  p.  iii.  of  "  Beitrag  zur  Kenntniss  der  Venenclas- 
ticitiit,"  in  "  Beitrage  zur  Anatomie  u.  Physiologic,  Pestgabe  f  lir  Carl  Ludwig, 
1874." 

^  "  Beitrage  zur  Mecbanismus  der  Blutbewegung  an  der  oberen  Thoraxapertur," 
in  Deutsch.  Zeitsch.  f.  Chirurgie,"  vol.  xvi.,  1881,  Dec.  20,  pp.  1-30. 

'  •'  Die  Oberschenkelvene  des  Menschen  in  Anatomischer  uud  Klinischcr 
Beziehung,"  1873,  p.  9. 


GYMNASTIC  MOVEMENTS  /  :   .    49 

effect,  the  stretch  position  of  the  arms,  if  maintained  for  half 
a  minute  or  so,  will  in  most  cases  partially,  and  in  some  cases 
entirely,  stop  the  flow  in  an  attack  of  epistaxis.' 

Effect  of  this  movement  on  the  chest  (see  pp.  45,  &c.). 

Every  time  that  a  negative  pressure  is  set  up  m  the  left  sub- 
clavian vein,  the  contents  of  the  thoracic  duct  are  sucked  up  into 
it;  with  the  establishment  of  a  positive  pressure  there  is  normally 
no  regurgitation  owing  to  the  competence  of  the  valves  at  the 
orifice  of  the  duct.  Thus  the  flow  of  lymph  in  the  duct  will  be 
furthered  by  all  arm  movements,  which,  like  the  above,  promote 
the  flow  in  the  left  subclavian  vein. 

The  following  movement  is  often  given  in  cases  of  paralysis, 
&c.  :— 

Standing  Arm  Swinging  Forwards  and  Backwards,  PA. 

The  patient  assumes  the  standing  position,  and  then  several 
times  swings  his  arm  alternately  forwards  and  backwards  as  far 
as  it  will  go.  He  may,  with  advantage,  stand  in  front  of  a  ladder 
and  try  to  swing  his  arm  high  enough  for  his  hands  to  catch 
hold  of  successive  rungs. 

The  flexors  and  extensors  of  the  shoulders  are  exercised. 

Flexion  and  extension  of  the  shoulder-joint  given  together 
with  movements  at  the  elbow-joint  will  be  described  on  p,  58. 

(2)     Of  the   Elbow-joint. 

There  are  two  divisions : — («)  Flexion  and  extension  of  the 
elbow-joint  given  simultaneojisly  with  movements  at  the  shoulder- 
joint,  (b)  Flexion  and  extension  confined  to  the  elbow-joint. 

It  will  be  best  to  discuss  at  once  the  muscular  phenomenon 
of  the  movements  of  flexion  and  extension  of  the  elbow-jomt 
executed  with  resistance  applied  at  the  wrist-joint  or  below  it, 
and  to  point  out  some  facts  which,  although  known  to  the  Ling 
school  at  least  fifty  years  ago,  seemed  to  have  sunk  into  oblivion 
asain.      Hartelius    does   not    mention    them    in    his   works   on 


'  See  Branting's  speeches  to  the  graduates  of  the  G.  C.  I.  on  April  3,  1843,  and 
April  8,  1848  (the  taauuscripts  of  these  are  preserved  in  the  library  of  the  G.C.I.) ; 
the  former  is  quoted  by  Georgii,  "  Kiuesitherapie,"  1847,  p.  92.  See  also  Georgii, 
"  Kinetic  Jottings,"  1880,  pp.  09,  70,  232.  Hj.  Ling,  "  De  Forsta  Begreppen  af 
Rorelseliiran,"  1866,  p.  132;  "Forkortad  Ofversigt  af  Allman  Rorelselara,"  1880, 
pp.  59,  &c.  ;  in  Branting's  "  Efterlemnade  Skrifter,"  1882,  p.  xxxii. 

4 


50     ELEMENTS    OF   KELLGREN'S   MANUAL   TREATMENT 

anatomy,^  and  Wide  does  not  refer  to  them  in  his  handbooks  ; 
and  they  are  not  to  be  found  in  modern  anatomical  text  books. 

As  regards  those  muscles  of  the  upper  arm  which  aid  in  these 
movements,  the  biceps  and  brachialis  anticus  act  in  flexion,  and 
the  triceps  and  anconeus  in  extension.  This  holds  good  whatever 
the  position  of  the  radio-ulnar  joints,  although  differences  in  that 
position  produce  great  differences  as  regards  those  mi;scles  of  the 
forearm  which  are  called  into  action,  as  follows  : — 

(1)  AVhen  the  forearm  is  completely  pronated.  Flexion  is 
assisted  by  the  extensors  on  the  back  of  the  forearm  together  with 
the  supinator  longus,  the  tension  being  felt  most  in  the  latter 
muscle  and  the  extensor  carpi  radialis  longior.  The  muscles  of 
the  upper  arm  do  not  work  so  hard  as  when  the  forearm  is 
completely  supinated,  and  the  brachialis  anticus  contracts  more 
powerfully  than  the  biceps,  as  the  latter  would  by  strong  contrac- 
tion supiuate  the  forearm.  If  the  movement  of  forearm  flexion 
(forearm  pronated)  be  given  with  AK  applied  over  the  ulna  or 
fifth  metacarpal,  the  amount  of  contraction  of  the  biceps  can  be 
felt  to  be  very  small  indeed,  being  much  less  than  when  the 
resistance  is  applied  over  the  radius. - 

Extension  is  aided  by  the  flexors  on  the  front  of  the  forearm, 
the  tension  being  felt  most  in  those  on  the  ulnar  side. 

(2)  When  the  forearm  is  in  the  mid-position.  Flexion  is 
assisted  by  the  extensors  and  flexors  on  the  radial  side  of  the 
forearm,  the  tension  being  felt  most  in  the  supinator  longus.  The 
extensors  and  flexors  on  the  ulnar  side  of  the  forearm  are  in 
action  during  extension. 

(3)  W^hen  the  forearm  is  completely  supinated.  The  flexors 
on  the  front  of  the  forearm,  assisted,  according  to  Hj.  Ling'  and 
Hartelius,*  by  the  pronator  radii  teres,  act  in  flexion  and  the 
extensors  in  extension,  as  ordinarily  described  in  text  books  on 

'  "  Liirobok  i  Menniskokroppens  Speciella  Anatomi,"  1867,  and  "  Liirobok  i 
^Menniskokroppens  Anatomi,"  1893. 

-  See.  Eulenbui-g,  "  Die  Schwedische  Heilgymuastik,"  1853,  p.  86.  Neumann, 
"  Das  Muskelleben  des  Menschen  in  Beziebung  auf  Heilgymnastik  und  Turnen," 
1855,  p.  122  &  123.  Branting's  remarks  on  tbe  supinator  longus  in  tbe  JIS.  of  his 
Lectures  on  Anatomy  (now  preserved  in  the  library  of  the  G.C.I. ),  and  his 
"  Efterlemnade  Skrifter,"  1882,  p.  33  and  fig.  15.  Hj.  Ling,  "  De  Forsta  Begreppen 
af  Rorelseliiran,"  1866,  pp.  175,  186. 

3  "  De  Forsta  Begreppen  af  Rorelseliiran,"  1866,  p.  187. 

*  "  Liirobok  i  Meuniskokroppens  Speciella  Anatomi,"  18G7,  p.  12u ;  "  Liirobok  i 
Menniskokroppens  Anatomi,"  1893,  p.  153. 


GYMNASTIC  MOVEMENTS  51 

the  subject.  The  tension  is,  however,  felt  most  in  the  muscles  of 
the  upper  arm,  not  in  those  of  the  forearm,  as  in  the  case  of 
pronation  or  the  mid-position. 

From  the  above  it  is  clear  that  the  supinator  longus  is  in 
action  during  flexion  whatever  may  be  the  position  of  the  radio- 
ulnar joints. 

All  the  foregoing  muscular  phenomena  can  be  easily  demon- 
strated in  the  living  subject.  Photographs  fail  to  show  them 
satisfactorily,  except  in  the  case  of  elbow  flexion.  In  fig.  Ki 
forearm  flexion  (forearm  pronated)  with  AE  is  being  executed, 
and  the  contracting  muscles  are  well  shown.  Fig.  18  shows  the 
same  with  the  forearm  supinated. 


If  it  is  desired  to  give  elbow  flexion  and  extension  with  elim- 
ination of  the  flexors  and  extensors  of  the  wrist  and  fingers, 
resistance  is  applied  over  the  front  and  back  respectively  of  the 
forearm  close  to  the  elbow.  In  this  case  practically  only  the 
following  muscles  are  called  into  action  : — Flexion  :  biceps,  bra- 
chialis  anticus,  supinator  longus  ;  extension  ;  triceps  and  anconeus. 

This  holds  good  for  whatever  the  position  of  the  radio-ulnar 
joints.  However,  on  flexion  with  the  forearm  pronated  the 
brachialis  anticus  works  harder  than  the  biceps,  if  the  movement 
be  given  with  AK  over  the  ulna  high  up.  The  I'everse  is  the  case 
if  AE  be  applied  over  the  radius  high  up. 


52     ELEMENTS   OF   KELLGREN'S    MANUAL   TREATMENT 

{a)    Movements    of   the    Elbojv-joint    given    simnltaneousUj  with 
Movements  at  the  Shoulder-joint. 

Reach  Grasp  Stoop  Fall  Standing  Double  Elbow  Flexion  and 
Extension,  PA. 

(This  may  also  be  called  "  fallinc^  forwards.") 

Having  assumed  reach  grasp  stoop  fall  standing  position,  the 
patient  flexes  his  elbow-joints,  causing  them  at  the  same  time  to 
pass  borizontall}'  outwards  and  forwards,  and  keeping  his  lower 


limbs,  trunk,  and  head  in  the  same  straight  line,  causes  the  latter 
as  a  whole  to  describe  the  sector  of  a  circle  whose  centre  is  the 
ankle-joint.  All  these  movements  are  executed  simultaneouslj', 
and  the  patient  reaches  swim  grasp  stoop  fall  standing  position. 
The  reverse  movement  is  then  executed  (fig.  17). 

The  muscles  placed  in  action  are  the  extensors  of  the  elbow- 
joint  and  some  of  the  shoulder-joint  muscles,  chiefly  the  upper 


GYMNASTIC  MOVEMENTS  53 

portion  of  the  pectoralis  major  and  the  anterior  part  of  the 
deltoid.  These  are  at  first  in  excentric,  then  in  concentric 
contraction.  In  addition,  most  of  the  anterior  muscles  of  the 
trunk  and  lower  limbs  are  contracted  in  order  to  preserve  the 
immobility  of  their  various  joints  (the  ankle  being,  of  course, 
an  exception).  The  posterior  muscles  of  the  trunk  are  relaxed. 
The  actual  movement  at  the  shoulder  joint  will  be  described 
on  p.  118. 

Standing  Doable  Arm  Stretching  Upwards,  PA. 

The  patient  assumes  the  standing  position  and  then  brings 
his  arms  into  bend  position  (see  fig.  6,  p.  18).  He  does  this 
by  flexing  his  elbow-joints  to  their  maximum,  partially  supina- 
ting  the  forearms,  and  also  to  some  extent  flexing  the  wrist 
and  metacarpo-phalangeal  joints.  The  upper  arms  are  kept 
vertical,  but  slightly  rotated  externally.  A  pause  of  a  second, 
or  even  less,  is  made,  and  the  humerus  being  then  flexed  simul- 
taneously to  its  maximum,  the  reverse  of  the  foregoing  move- 
ments is  executed,  the  arms  coming  thus  to  stretch  position 
(fig.  7,  p.  18). 

This  exercise  is  used  in  order  to  bring  the  patient  into  stretch 
position,  as  is  also  the  movement  of  standing  double  arm  raising 
forwards  and  upwards,  PA  (p.  46).  The  flexors  of  the  elbow, 
wrist  and  metacarpo-phalangeal  joints,  and  the  supinators  of  the 
forearm  are  at  first  placed  in  action ;  then  their  antagonists, 
together  with  the  flexors  of  the  shoulder-joint,  are  used  to  bring 
the  arms  into  stretch  position. 

Standing  Double  Arm  Stretching  Outwards,  PA. 

Is  the  same  as  the  last,  except  that  in  the  second  stage  of  the 
movement  there  is  abduction  of  the  humerus  through  a  right 
angle  instead  of  flexion.  Therefore  at  the  close  of  the  exercise 
the  arms  are  in  yard  position  (fig.  8,  p.  20).  The  muscles 
involved  are  the  same  as  in  the  case  of  the  last  exercise, 
excepting  that  the  abductors  of  the  humerus  are  used  instead 
of  the  flexors. 

Half  Lying  Double  Arm  Bending  and  Stretching,  AB. 

See  p.  91. 


54     ELEMENTS   OF   KELLGREN'S    MANUAL    TREATMENT 

(h)  Movements  Confined  to  the  Elhotc-joint. 

For  the  execution  of  these  the  upper  arm  must  be  fixed  either 
by  the  assistant  or  by  the  patient. 

(1)  The  upper  arm  is  fixed  by  the  assistant. 

Sitting  Forearm  Flexion  and  Extension,  AR. 

The  patient  assumes  the  sitting  position  with  one  arm  in 
heave  position,  and  the  humerus  is  fixed  by  support  at  the 
elbow  and  shoulder.  The  movements  of  flexion  and  extension  at 
the    elbow-joint    are    then    executed,    with    the    forearms    either 


pronated,  supinated,  or  in  the  mid-position.  The  resistance  is 
applied  as  in  the  case  of  the  last  exercise  (fig.  18). 

The  muscles  that  act  are  the  flexors  and  extensors  of  the 
elbow-joint,  as  described  on  pp.  49  to  51  ;  the  muscles  of  the 
shoulder-joint  (with  the  exception  of  the  biceps  and  triceps)  are 
not  brought  into  play,  being  eliminated  by  fixation. 

By  transferring  the  grasp  of  the  assistant  to  near  the  elbow- 
joint,  the  muscles  of  the  forearm  (except  the  supinator  longus) 
can  be  eliminated  (see  p.  51.) 


GYMNASTIC  MOVEMENTS  55 

el)  The  upper  arm  is  fixed  by  the  patient. 

Heave  Sitting  Double  Forearm  Extension  and  Flexion,  AR. 

From  the  heave  sitting  position  the  patient,  keeping  his  upper 
arms  immovable,  extends  his  forearms  until  yard  position  is 
reached,  and  then  the  reverse  movement  executed,  both  with  AR. 
The  point  of  application  of  the  resistance  varies  with  the  position 


of  the  radio-ulnar  joints  ;  if  the  forearms  are  pronated,  it  will  be 
first  over  the  palmar  and  then  over  the  dorsal  aspects  of  the 
metacarpals  ;  if  supinated,  the  reverse  ;  if  in  the  mid-position, 
first  over  the  inner  side  of  the  fifth,  and  then  over  the  outer  side 
of  the  second  metacarpal  (fig.  19). 

The  humerus  is  fixed  at  the  shoulder-joint  by  the  abductors 
and  some  of  the  posterior  scapular  muscles.     There  is  a  tendency 


56     ELEMENTS    OF   KELLGREN'S   MANUAL    TREATMENT 

in  patients  unaccustomed  to  this  exercise  to  bring  the  pectorals 
into  play  if  the  forearms  are  supinated  (see  p.  92). 

The  muscles  of  the  elbow-joint  called  into  action  are  first  its 
extensors  and  then  its  flexors,  as  described  on  pp.  49-51. 

(3)   Of  the   Wpist-joint. 
Sitting  Hand  Flexion  and  Extension,  AB. 

The  patient's  forearm  is  fixed,  and  the  proximal  ends  of  his 
fingers  are  grasped  by  the  assistant.  While  the  latter  keeps  up 
traction  away  from  the  forearm,  and  resists,  the  patient  alter- 
nately flexes  and  extends  his  wrist-joint  to  its  fullest  extent 
(fig.  49,  page  106). 

The  flexors  and  extensors  of  the  wrist  are  exercised.  By 
transferring  the  assistant's  grasp  to  the  distal  end  of  the  meta- 
carpus the  movement  specially  influences  the  flexors  and  extensors 
that  are  inserted  into  the  wrist-joint  and  metacarpus,  the  flexors 
and  extensors  of  the  fingers  being  less  active. 

Ulnar  or  radial  flexion  of  the  hand,  active  or  passive,  with  the 
forearm  fixed,  may  be  administered  if  it  be  specially  desired  to 
exercise  the  muscles  concerned  in  these  movements.  They  can 
also  be  exercised  by  means  of  elbow  flexion  or  extension,  with  the 
forearm  in  the  mid-position  (p.  50). 

(4)   Of  the   Metacarpo-Phalangeal  and  Inter-Phalangeal 
joints. 

In  the  case  of  the  former  the  metacarpals  are  fixed,  and  the 
inter-phalangeal  joints  being  kept  fully  extended  the  movements 
of  flexion  and  extension  of  the  fingers,  with  or  without  resistance, 
are  executed.  If  given  with  AE  the  assistant's  grasp  is  over  the 
ends  of  the  fingers,  traction  being  applied  away  from  the  meta- 
carpus. 

The  muscles  placed  in  action  are  the  flexors  and  extensors 
of  the  phalanges,  assisted  during  flexion,  in  the  case  of  the  fingers, 
by  the  lumbricals  and  some  of  the  interossei,  which,  by  means  of 
their  insertion  into  the  extensor  expansion,  enable  the  patient 
to  keep  the  inter-phalangeal  joints  extended. 

If  duplicate  movements  of  all  the  inter-phalangeal  joints  of  the 
fingers   are   required   in   addition,  the  movement  of  alternately 


GYMNASTIC  MOVEMENTS  57 

opening  and  closing  the  fist  will  effect  this  ;  resistance  can  be 
applied  over  the  terminal  phalanges  (fig.  "20).  The  action  of  the 
lumbricals  and  iuterossei  is  in  this  case  eliminated,  the  flexors  and 
extensors  of  the  metacarpo-phalangeal  and  inter-phalangeal  joints 
doing  all  the  work. 

If  it  is  desired  to  isolate  and  exercise  one  special  inter- 
phalangeal  joint,  the  bone  immediately  above  it  is  fixed  with  one 
hand,  and  the  one  immediately  below  it  grasped  with  the  other ; 
traction  of  the  latter  being  exercised  away  from  the  former,  the 
movements  of  flexion  and  extension  are  then  executed. 

The  flexors  and  extensors  respectively  of  that  particular  joint 
are  exercised. 


II. — Flexion  and  Extension  of  the  Lower  Extremity. 

(1)   Of  the    Hip-joint. 
There  are   two    divisions  : — (a)  Flexion    and   extension   con- 
fined to  the  hip-joint,     (b)  Flexion  and  extension  of  the  hip-joint 
given  simultancoushj  with  Jiexion  and  extension  of  the  knee-joint. 

(a)  Flexion  and  Extension  confined  to  tlic  Hip-joint. 
Lying  Leg  Flexion,  PR,  Extension,  AR. 

The  patient  assumes  the  lying  position  with  neck  firm.^     The 

assistant   with   one   hand   grasps    the    heel    of   the    limb   to   be 

'  In  all  leg  and  foot  exercises  performed  from  lying  or  half  lying  positions  the 
patient's  arms  should  be  placed  in  neck  firm  position,  unless  otherwise  stated. 


5S     ELEMENTS    OF   KELLGREN'S    MANUAL    TREATMENT 

exercised  and  places  the  other  hand  over  the  iliac  crest  of  that 
side  to  steady  it.  Maintaining  traction  away  from  the  pelvis,  he 
lifts  up  the  foot  so  as  to  cause  flexion  at  the  hip-joint,  the 
patient  meanwhile  resisting  and  keeping  his  knee  fully  extended. 
When  further  flexion  is  impossible  without  some  bending  occur- 
ring of  the  latter  joint,  the  reverse  movement  is  executed  with 
AR  (fig.  21).  The  effect  of  this  exercise  can  be  increased  by 
the  assistant  keeping  the  ankle  strongly  flexed  the  whole  time. 


In  the  course  of  the  foregoing  exercise  the  patient  has  to 
fix  the  pelvis,  first  resist  flexion,  and  then  perform  extension 
of  his  thigh.  The  pelvis  is  fixed  by  the  erector  spina3,  quadratus 
lumborum,  and  posterior  attachments  of  the  anterior  abdominal 
muscles.  The  muscles  concerned  in  the  actual  movement  at  the 
hip-joint  are  its  extensors,  which  are  first  excentrically  and  then 
concentrically  contracted.  The  great  sciatic  nerve  is  first  elon- 
gated and  then  shortened. 

Effect  of  this  exercise  on  the  venous  flow.  The  return  of 
venous  blood  from  the  leg  is  promoted,  because  in  the  first  place 
it  proceeds  in  the  direction  of  gravity,  and  in  the  second  because 
a  special  anatomical  mechanism  to  aid  it  comes  into  play.'     In 

'  The  effect  it  produces  iu  this  exercise  is,  however,  by  no  means  so  marked  as  in 
the  case  of  leg  rolling  (sec  pp.  107,  &c.),  and  some  other  movements. 


GYMNASTIC  MOVEMENTS  59 

its  entire  course  in  the  thigh,  the  femoral  vein  has  its  wahs 
attached  to  the  adjacent  over-  and  under-lying  muscles,  fasciae, 
&c.  ;  alternate  contraction  and  relaxation  of  these  muscles,  or 
even  alternate  passive  elongation  and  shortening,  will  altei'nately 
open  out  and  close  the  vein,  setting  up  first  a  suction  force  and 
then  a  pumping  force.  This  mechanism  is  best  marked  just  in 
the  region  of  the  fossa  ovalis.'  (Similar  arrangements  for  fur- 
thering the  venous  flow  have  already  been  described  in  the  case 
of  the  axillary,  subclavian,  and  internal  jugular  veins,  p.  48). 

During  the  performance  of  the  exercise  just  described  there 
is  depletion  of  the  legs  and  an  increase  in  the  amount  of  blood 
in  the  pelvic  organs ;  after  the  exercise  is  over  the  opposite 
obtains. 

All  passive  flexions  of  the  thigh  diminish  the  downward  pull 
on  Poupart's  ligament  by  withdrawal  of  the  tension  exercised 
upon  it  by  the  iliac  fascia  lata.  Thus  all  such  flexions,  which 
entail  no  effort  on  the  part  of  the  iliacus,  psoas,  or  anterior 
abdominal  muscles,  bring  about  a  diminution  in  the  intra- 
abdominal pressure. 

Lying  Leg  Flexion,  AB,  Extension,  PR. 

The  movement  is  the  same  as  for  the  last  exercise,  except- 
ing that  the.  patient  does  the  flexion  while  the  assistant  resists 
over  the  dorsum  of  the  foot  just  below  the  ankle-joint ;  then 
the  assistant  brings  about  the  extension  with  PE  (fig.  22). 

The  pelvis  is  fixed  by  the  anterior  abdominal  muscles,  and 
there  is  a  tendency  to  keep  the  ribs  immovable  in  order  to 
serve  as  fixed  points  for  the  origin  of  those  muscles,  and  with 
this  there  is  a  tendencj'  to  inhibit  contraction  of  the  diaphragm, 
in  consequence  of  the  increased  intra-abdominal  pressure.  This, 
if  unchecked,  would  lead  to  an  almost  entire  stoppage  of  respira- 
tion, and  must  on  no  account  be  allowed. 

The  spinal  column  is  fixed  by  the  erector  spina?  in  order 
to  counteract  the  pull  on  the  anterior  abdominal  muscles,  which 
would,  if  unopposed,  flex  the  trunk  upon  itself.  The  flexors  of 
the  hip  perform  the  actual  movement  at  that  joint,  being  first 
concentrically   and   then   excentricall}'  contracted  ;    the   nmscles 

'  Brauue.  "  Die  Oberscheukelvene  des  Menschen  in  Anatomischer  und  Klin- 
ischer  Beziehuug,"  187.3. 


6o     ELEMENTS    OF   KELLGREN'S   MANUAL    TREATMENT 

actually  concerned  are,  accorduig  to  Hj.  Ling,'  the  iliopsoas, 
rectus  femoris,  sartorius,  pectineus,  anterior  part  of  the  adductors, 
tensor  fasciip  femoris,  and  anterior  portion  of  the  gluteus  medius. 
In  order  to  give  the  psoas  an  increased  length,  so  as  to  increase  its 
absolute  power,  the  lumbar  vertebrte,  as  the  movement  proceeds, 
becomes  somewhat  convex.  This  is  effected  by  allowing  the 
contraction  of  the  erector  spins  in  the  lumbar  region  to  give  way 
a  little,  and  the  anterior  abdominal  muscles  to  shorten  somewhat, 
both,  however,  being  powerfully  in  action  the  whole  time.     The 


same  movement  as  this  is  found  in  all  exercises  entailing  strong 
action  of  the  flexors  of  the  hip.^  The  greater  the  amount  of 
external  rotation  of  the  thigh,  the  harder  do  the  psoas,  iliacus, 
and  sartorius  work.^  The  quadriceps  cruris  in  its  lower  part  has 
to  act  to  keep  the  knee-joint  extended,  additional  strain  being 
thrown  on  it,  the  further  the  movement  of  flexion  proceeds,  from 
increasing  tension  in  the  hamstrings.  During  the  reverse  move- 
ment the  normal  curve  in  the  lumbar  vertebrte  is  restored  by 
the  lumbar  portion  of  the  erector  spinte  shortening  again,  and  the 

'  "  De  Forsta  Begroppen  af  Rorelseliiran,"  1866,  p.  187. 
-  See  Hj.  Ling,  op.  cit,  p.  205. 
^  See  Hj.  Ling,  op.  cit.,  p.  187. 


GYMNASTIC  MOVEMENTS  6i 

extra  strain  on  the  lower  part  of  the  quadriceps  cruris  is 
gradually  removed. 

The  flexors  of  the  ankle-joint  can  be  eliminated  if  the  resist- 
ance be  applied  above  the  ankle  instead  of  below  it. 

Ail  movements  entailing  strong  action  of  the  anterior  ab- 
dominal muscles  in  all  probabilit}'  act  reflexly  in  a  stimulatory 
way  on  the  abdominal  contents. 

Lying  Double  Leg  Flexion  and  Extension,  PA., 

is  the  same  as  the  last,  oulj*  without  resistance,  and  is  executed 
w'ith  both  legs  simultaneously.  This  movement  can  also  be  given 
in  a  strong  subject  as  flexion,  AE,  extension,  PR,  in  which  case 
the  patient's  elbows  have  to  be  fixed  by  a  second  assistant. 

The  effects  are  as  from  the  last  exercise,  only  much  more 
marked  ;  greater  convexity  results  in  the  lumbar  vertebrae,  and 
the  anterior  abdominal  muscles  are  placed  very  strongly  in  action. 
The  effects  will,  in  fact,  be  specially  manifested  on  the  abdoniinal 
contents. 

Side  Lying  Leg  Carrying  Forwards  and  Backwards,  AR. 

The  patient  assumes  the  side  lying  position  ;  the  assistant, 
steadying  the  pelvis  with  one  hand,  with  the  other  grasps  the 
ankle-joint  of  the  leg  which  lies  uppermost.  The  patient,  con- 
tinually keeping  that  leg  horizontal  and  the  knee-joint  fully 
extended,  flexes  the  hip-joint  as  far  as  it  will  go  with  Alt,  and 
then  resists  while  the  reverse  movement  is  executed ;  afte^  a 
pause  of  a  second  or  so,  he  extends  his  hip-joint  with  AE,  and 
then  resists  while  the  reverse  takes  place,  keeping  his  knee- 
joint  fully  extended  as  before.  The  effects  are  similar  to  those 
of  the  exercises  described  on  pp.  57-61. 

The  following  movement  may  be  given  in  cases  of  paralysis, 
hip-joint  disease,  &:c  : — 

Standing  Leg  Swinging  Forwards  and  Backwards,  PA. 

The  patient  assumes  the  standing  position,  and  then  lifts  up 
the  pelvis  of  one  side  (say  the  right)  a  little,  so  that  the  right 
heel  does  not  touch  the  ground.  Then  he  swings  the  right  leg 
alternately  forwards  and  backwards  several  times.      As  the  leg 


62     ELEMENTS    OF   KELLGREN'S   MANUAL    TREATMENT 

hangs  by  its  own  weight  it  exerts  a  certain  amount  of  traction, 
and  so  will  diminish  pain  from  stiffness,  &c.,  in  the  hip-joint. 
The  flexors  and  extensors  of  the  hip-joint  are  exercised. 

Forwards  Lying  Leg  Flexion,  PP,  Raising,  AR. 

The  patient  lies  in  the  forwards  lying  position.  The  assistant 
uses  one  hand  to  grasp  the  ankle  of  the  leg  that  is  to  be  exer- 
cised, steadying  the  pelvis  of  that  side  with  his  other  hand. 
Then  with  traction   away  from   the  trunk,   he    brings  that    leg 


ki.       ^U                     ^^^K^^^tmTA 

Im 

of     ^^ 

IH 

^^^BHK 

^■IS^^^^F  ' 

(with  the  knee  quite  extended)  down  over  the  side  of  the  couch, 
flexing  it  until  an  angle  of  60"  or  so  with  the  horizontal  is 
reached.  The  patient  thereupon  executes  the  reverse  movement 
with  AE  over  the  back  of  the  ankle,  traction  being  maintained  as 
before. 

The  effect  of  the  exercise  is  increased  if  the  patient,  instead 
of  ceasing  to  raise  his  leg  when  it  has  reached  the  horizontal 
position,  continues  to  extend  it  as  much  as  possible  above  the 
couch,  and  then  resists  while  the  assistant  presses  it  down  to  the 
original  position  again. 


GYMNASTIC  MOVEMENTS  63 

The  movement  is  one  of  flexion  and  extension  of  the  hip- 
joint  together  with  a  certain  amount  of  abduction  and  adduc- 
tion, which  are  necessary  in  order  to  enable  the  hmb  to  be 
brought  over  the  side  of  the  couch  and  back  again. 

The  muscles  involved  are  those  which  bring  about  extension 
and  adduction  of  the  thigh.  The  gluteus  maximus  is  specially 
affected,  being  first  elongated,  and  then  by  its  concentric 
contraction  performing  both  extension  and  adduction  of  the 
hip-joint. 

This  exercise  is  a  very  good  one  for  disorders  of  coordination. 
This  is  because  the  patient  cannot  look  at  the  part  actually 
moved,  and  has  thus  to  depend  on  his  sensory  functions  alone 
for  correct  performance.  The  same  advantage  pertains  to  other 
exercises  in  which  the  use  of  sight  is  physiologically  eliminated. 

(b)  Flexion  and  Extension  of  the  Hip-joint  given  simidtaneoHsIij 
with  Flexion  and  Extension  of  the  Knee-joint. 

Half  Lying  Leg  Flexion,  PP,  Extension,  AR. 

(This  exercise  may  also  be  given  with  both  legs  at  once.) 

The  patient  assumes  the  half  lying  position.  The  assistant, 
grasping  the  patient's  heel  with  one  hand,  lays  the  other  to 
the  outer  side  of  and  below  the  knee-joint.  Then,  keeping  up 
external  rotation  of  the  thigh,  he  flexes  and  abducts  the  hip  and 
flexes  the  knee  as  far  as  these  joints  will  allow  him,  continually 
keeping  the  heel  along  the  middle  line.  The  patient  then 
executes  the  reverse  movement  with  AE  applied  under  the  heel, 
the  assistant's  other  hand  being  kept  at  the  knee-joint  to  steady 
it  (fig.  24). 

The  extensors  and  adductors  of  the  thigh,  and  extensors  of 
the  knee  are  first  passively  extended,^  and  then  concentrically 
contracted.  The  internal  rotators  of  the  thigh  are  also  similarly 
affected,  though  to  a  much  less  extent.  If  the  first  part  of  the 
movement  be  given  with  flexion,  PA,  or  AE  (instead  of  PP), 
the  flexors,   abductors,   and    external  rotators  of   the  thigh  and 

'  According  to  Hj.  Ling,  these  as  well  as  the  muscles  of  the  calf  are  specially 
susceptible  to  passive  elongation.  See  "  De  FiJrsta  Begreppen  af  RorelselUran," 
1866,  pp.  218-219. 


r.4     ELEMENTS    OF    KELLGREN'S    MANUAL    TREATMENT 

fiexors  of  the  knee  contract  actively  instead  of  being  passively 
shortened. 

If  the  thigh  be  first  rotated  internally  (so  that  the  toes  point 
upwards  instead  of  outwards)  it  is  possible,  by  keeping  the  knee- 
joint  and  heel  along  the  middle  line  (thus  eliminating  rotations, 
abduction,  and  adduction  of  the  femur),  to  convert  the  move- 
ment into  one  of  pure  flexion  and  extension  of  the  hip-  and  knee- 
joints. 

Effect  of  this  exercise  on  the  venous  flow. — The  venous  flow 
is  specially  promoted  by  : — 


WPM 

'  iK\l 

HrJl  /JhI 

'tLiSD 

I^^BhB^^^^E^^^^. 

i^ 

^^^^^^^WIPp-                  •- «»»* 

(1)  The  existence  of  the  special  mechanism  in  the  case  of  the 
femoral  vein,  by  means  of  which  movements  of  the  muscles 
to  which  the  outer  wall  of  the  vessel  is  attached  alternately  set 
up  a  suction  and  force  pump  in  it.  This  has  been  referred  to 
on  p.  59. 

(■2)  A  similar  mechanism  obtains  through  the  attachment  of 

the  walls  of  the  femoral   vein,  just    at   its    commencement,   to 

the  foramen  in  the  adductor  magnus.' 

'  Braune,    "Die  Oberschenkelvene  des   Sleuschen  in  Anatomischer  und  Kliu- 
ischer  Beziehung,"    1873. 


GYMNASTIC  MOVEMENTS  65 

(3)  The  walls  of  the  poplitecal  vein  are  in  a  like  manner 
attached  to  the  popliteal  fascia,  which  is  alternately  stretched 
and  relaxed  in  certain  movements  of  the  knee-joint,  unless 
hyperflexion  is  performed,  in  which  case  the  vein  is  forcibly 
compressed.' 

Half  Lying  Leg  Flexion,  PA,  Extension,  PR. 

(This  exercise  may  also  be  executed  with  both  legs  at  once). 

The  patient  first  draws  his  leg  up  into  the  same  position  as 
the  assistant  placed  it  in  the  first  half  of  the  last  exercise.  The 
assistant  then  places  one  hand  on  the  patient's  shoulder  to  steady 
him,  and  the  other  hand  just  above  the  knee ;  then,  with  resist- 
ance from  the  patient,  he  presses  the  knee  down,  thus  causing 
extension  of  the  thigh.  Meanwhile,  the  patient  must  extend 
his  knee-joint  so  as  to  keep  his  foot  off  the  couch  until  the  very 
moment  of  completion  of  the  movement,  when  the  whole  limb 
returns  to  the  original  position. 

The  flexors,  abductors,  and  external  rotators  of  the  thigh 
are  first  concentrically  and  then  excentrically  contracted  ;  the 
extensors  of  the  knees  are  also  somewhat  contracted,  first  excen- 
trically and  then  concentrically.  The  anterior  abdominal  muscles 
are  powerfully  contracted  in  order  to  fix  the  pelvis,  and  the 
erector  muscles  of  the  back  have  to  act  in  order  to  fix  the  ribs. 
(For  their  special  action  see  pp.  59,  60.) 

As  with  the  last  exercise,  rotations,  abduction  and  adduction 
of  the  hip-joint  may  be  eliminated. 

Stretch  Grasp  Standing  Knee  Flexion   (Raising),  AR,   Pressing 
down,  PR. 

The  patient  assumes  the  stretch  grasp  standing  position,  and, 
keeping  up  external  rotation  of  the  hip,  flexes  and  abducts  his 
thigh  as  much  as  possible,  letting  his  knee-joint  be  flexed  mean- 
while so  that  the  lower  leg  hangs  vertical  throughout.  This  is 
effected  with  AE  just  above  the  knee-joint.  The  reverse  move- 
ment is  then  executed  with  PR. 

The  pelvis  is  fixed  by  the  anterior  abdominal  muscles.  The 
actual  movement  is  achieved  by  the  flexors  of  the  hip-joint,  which 
are  first  concentrically  and  then  excentrically  contracted.     The 

'  Braune,    "Die   Oberschenkelvene   des   ilenschen   in    Auatomischer   und   Klin- 
ischer  Beziehung,"  1873  (p.  3). 

5 


66      ELEMENTS  OF  KELLGREK'S  MANUAL   TREATMENT 

abductors  of  the  thigh  are  also  involved.  As  the  assistant's 
grasp  is  above  the  knee,  practically  all  the  muscles  of  the 
lov?er  leg  are  thrown  out  of  action.  The  changes  in  the  lumbar 
vertebrae  are  the  same  as  those  specified  on  p.  60. 

As  with  the  last  two  exercises,  rotations,  abduction  and 
adduction  of  the  hip-Joint  may  be  eliminated. 

(2)     Of  the  Knee-joint. 

There    are  two    divisions  : — (a)    Flexion    and    extension    of 

the   knee-joint  given    simultaneously    with    other  movements   at 

the  hip-joint.  {h)  Flexion  and  extension  confined  to  the  knee- 
joint. 

(a)  Flexion  and  Extension  of  the  Knee-joint  given  simultaneously 
with  other  Movements  at  the  HijJ-joint. 

Standing  Double  Knee  Bending,  PA. 

From  the  initial  position  the  patient,  by  bending  his  knees 
and  keeping  them  well  outwards,  taking  care  that  his  heels  do 
not  leave  the  ground,  comes  to  knee  bend  standing  position.  The 
reverse  movement  is  then  executed. 

The  extensors  of  the  knees,  extensors,  adductors,  and 
rotators  of  the  hip,  and  extensors  of  the  ankle  (excepting  the 
upper  part  of  the  gastrocnemius)  are  placed  in  action.  This 
movement  is  administered  chiefly  in  order  to  stretch  the  posterior 
calf  muscles. 

Toe   Standing  Double  Knee   Bending,   PA. 

The  patient  first  rises  on  his  toes  until  toe  standing  position 
is  reached  (see  p.  71)  ;  then,  by  bending  his  knees  and  keeping 
them  well  outwards,  he  comes  into  knee  bend  toe  standing  posi- 
tion. These  movements  are  then  executed  in  the  reverse  way  in 
the  reverse  order  (fig.  9,  p.  20). 

Varying  positions  of  the  arms  may  be  used,  such  as  stretch 
lean,  reach  lean,  &c. 

The  muscles  placed  in  action  are  the  same  as  in  the  case  of 
the  last  exercise,  with  the  addition  of  the  plantar  muscles,  which 
serve  to  maintain  the  arches  of  the  foot. 

The  above  movement,  executed  slowly  from  the  standing 
position  (with  the  correct  specific  rate  of  execution)  causes  the 
pulse  to  become  slower  a  few  seconds  after  its  completion.     The 


GYMNASTIC   MOVEMENTS  67 

same  effect  has  been    observed   after   many   other  leg  exercises 
(Petersen,'  Hartehus  -). 

Reach  Grasp  Step  Standing   Knee   Flexion  and  Extension,  PA. 

This  exercise  is  a  combination  of  reach  grasp  step  standing 
double  elbow  flexion  and  extension,  knee  and  thigh  flexion  and 
extension,  PA.  Suppose  the  left  leg  to  be  placed  in  step  posi- 
tion. While  doing  double  elbow  flexion  and  falling  forwards,  as 
described  on  pp.  •5"2,  &c.,  the  patient  simultaneously  flexes  his 
left  knee  and  thigh,  keeping  up  external  rotation  of  the  hip-joint 
and  abducting  it  as  well.  When  the  body  has  reached  swim 
grasp  stoop  fall  standing  position,  the  reverse  movement  i 
executed  ;  but  instead  of  being  terminated  at  step,  position,  it 
is  to  be  continued  until  the  left  knee  is  fully  extended,  to  allow 
of  which  some  flexion  of  the  right  thigh  and  extension  of  the 
right  ankle  takes  place.  The  right  knee,  however,  must  con- 
stantly be  kept  fully  extended  (fig.  80). 

The  efi'ects  of  this  exercise,  apart  from  those  produced  by  the 
falling  forwards  and  the  arm  movements,  are  as  follows  ; — At  first 
the  flexors  of  the  left  knee,  flexors  and  abductors  and  external 
rotators  of  the  left  thigh,  are  placed  in  action,  although  only  to  a 
moderate  degree,  as  the  movement  of  the  leg  is  to  a  great  extent 
an  involuntary  accompaniment  of  falling  forwards,  During  the 
second  part  of  the  movement  the  antagonists  of  the  above  muscles 
are  placed  in  action,  especially  the  extensors  of  the  hip-joint. 
The  further  the  movement  proceeds,  the  more  a  sense  of  tension 
is  felt  in  the  whole  of  the  posterior  muscles  of  the  left  leg,  and 
this  becomes  very  marked  towards  the  close  of  the  movement. 
The  higher  the  foot  was  placed  to  begin  with,  the  more  will  this 
tension  manifest  itself. 

Many  of  the  muscles  of  the  right  leg  are  brought  into  play  in 
order  to  maintain  equilibrium  and  to  keep  the  knee  extended. 

Reach  Grasp  Step   Standing  Trunk  Raising,  PA. 

The  patient  assumes  reach  grasp  step  standing  position  and 
then  flexes   the  knee  that  is  in  step  position,  say  the  left  one, 

'  "  lagttagelser  over  en  laagsom  Benbevaegelses  Indflydelse  pa  Pulsons 
Hastighed,"  in  Tidskrift  i  Gymnastik,  1880,  pp.  795,  &c.  ;  and  "  lagttagelser  over 
Benbevaegelsers  Indflydelse  pa  Pulsens  Hastighed,"  ibid.,  1881,  p.  926,  &c. 

■-  "  Den  Mekaniska  Agentens  Porhallande  till  Hjertsjukdomar,"  ibid.,  1886, 
p.  402,  &c. 


68     ELEMENTS    OF   KELLGREN'S   MANUAL   TREATMENT 

until  it  comes  to  rest  against  the  apparatus,  so  that  the  lower 
leg  lies  vertically.  Keeping  his  head  and  trunk  well  erect  and 
his  right  leg  vertical,  he  slowly  extends  both  knee  and  thigh  of 
the  left  side,  thus  raising  himself  slowly  off  the  ground,  using 
his  arms  as  a  help,  meanwhile  extending  his  shoulders  and 
flexing  his  elbows  in  order  to  preserve  the  erect  position  of  the 
trunk.  The  movement  is  continued  until  both  knee  and  thigh 
are  fully  extended,  so  that  the  patient  ultimately  stands  up 
against  the  ladder,  suppoi'ted  by  his  left  foot  and  his  arms. 
The  arms,  however,  should  be  used  as  little  as  possible  to  aid  the 
raising  process,  in  order  to  throw  the  maximum  amount  of  work 
onto  the  left  leg.     The  reverse  movement  is  then  executed. 

The  extensors  of  the  knee  and  thigh  of  the  limb  in  step 
position  are  placed  strongly  in  action.  Some  of  the  muscles  of 
the  arms  are  also  involved,  especially  the  extensors  of  the 
shoulders,  and  flexors  of  the  elbow-joints  and  fingers. 

(b)     Flexion  and  Extension  confined  to  the  Knee-joint. 

Sit  Lying  Knee  Extension  and  Flexion,  PP. 

The  sit  lying  position  is  assumed  with  neck  firm  ;  the  assistant 
grasps  the  patient's  foot  across  the  instep  with  one  hand,  and 
places  his  other  hand  anteriorly  just  above  the  anterior  surface 
of  the  knee-joint  in  order  to  fix  the  thigh.  Keeping  up  traction 
away  from  the  latter,  he  several  times  alternately  performs 
extension  of  the  lower  leg  up  to  the  horizontal,  and  then  flexion 
down  to  the  vertical  ffig.  2.jl. 


GYMNASTIC    MOVEMENTS.  69 

The  effects  will  be  similar  to  those  resulting  from  energetically 
given  passive  movements  (see  p.  38),  the  areas  affected  being 
the  flexor  and  extensor  group  of  muscles  of  the  knee-joint.  The 
special  mechanism  that  aids  the  flow  in  the  popliteal  vein  has 
already  been  referred  to  (p.  65). 


Sit  Lying  Knee  Extension,  AR,  Flexion,  PR. 

The  position  of  the  patient  and  the  grasp  of  the  assistant 
are  the  same  as  in  the  foregoing  exercise.  The  assistant,  keeping 
up  traction  away  from  the  thigh,  resists  while  the  patient  extends 
his  lower  leg  up  to  the  horizontal.  Then  the  reverse  movement 
is  executed  with  PR. 

The  extensors  of  the  knee  and  flexors  of  the  ankle  are 
exercised.  The  latter  group  of  muscles  would  be  eliminated  if 
the  assistant  transferred  his  grasp  to  above  the  ankle-joint. 

Forwards  Lying  Knee  Flexion,  AR,  Extension,  PR. 

The  patient  assumes  the  forwards  lying  position ;  the  assistant 
uses  one  hand  to  fix  the  thigh  just  above  the  knee-joint  pos- 
teriorly, and  with  the  other  hand  grasps  the  heel.  While  the 
assistant  performs  traction  away  from  the  knee,  and  offers 
resistance,  the  patient  flexes  his  lower  leg  from  the  horizontal  to 
the  vertical,  or  as  far  as  it  will  go  ;  the  reverse  movement  is 
then  executed  with  PE. 


(3)  Of  the  Ankle-joint. 

Half  Lying  Foot  Flexion  and  Extension,  AR. 

The  assistant  sits  at  the  side  of  the  foot  to  be  exercised,  so 
as  to  look  transversely  across  it,  as  in  fig.  26.  The  lower  leg  of 
the  patient,  just  above  the  ankle-joint,  rests  upon  the  knee  of 
the  assistant,  who  uses  one  hand  to  complete  the  fixation  of  the 
lower  leg  by  grasping  it  on  its  corresponding  anterior  aspect, 
exercising  traction  away  from  the  trunk  in  the  case  of  disease  of 
the  hip  or  knee-joint  of  the  limb.  The  assistant's  other  hand  is 
applied  to  the  foot,  so  that  the  palm  rests  against  the  plantar 


70     ELEMENTS   OF   KELLGREN'S   MANUAL    TREATMENT 

aspect  of  the  distal  ends  of  the  metatarsus  ;  and  the  fingers 
enclosing  the  foot  rest  against  the  corresponding  dorsal  aspect. 

Then  ■nith  AR  applied  over  the  dorsum,  the  patient  flexes  his 
foot  as  far  as  possible,  after  which,  with  AR  under  the  sole,  he 
extends  it  to  the  maximum  (fig.  2(3).     (See  also  chap,  vi.) 

At  first  the  flexors  of  the  ankle  and  extensors  of  the  toes  are 
in  action,  and  then  their  antagonists,  the  latter  including  many 
of  the  plantar  muscles,  which  serve  to  maintain  the  longitudinal 
arch  of  the  foot.  The  intertarsal  joints  participate  in  the 
movement. 


Half  Lying  Double  Foot  Flexion  and  Extension,  AR., 

is  the  same  movement  as  the  last  but  performed  with  both  feet 
at  once. 


The  assistant  sits  at  the  feet  of  the  patient  so  as  to  face  him 
and  supports  the  latter's  lower  legs  just  above  the  ankle-joints, 
as  in  fig.  27.  He  grasps  each  foot  with  one  hand  but  not  in  the 
same  manner  as  in  the  last  exercise.  Each  hand  is  placed  so  that 
the  thumb,  instead  of  the  palm,  lies  on  the  plantar  aspect  of  the 
distal  end  of  the  metatarsus  ;  the  palm  rests  against  the  external 
aspect  of  the  fifth  metatarsal  bone,  and  the  fingers  lie  over  the 
dorsal  aspect  of  the  metatarsals. 

The  same  movement  as  in  the  case  of  the  last  exercise  is  then 
executed,  but  with  both  feet  simultaneously  instead  of  one  at  a 
time.  The  same  muscles  are  called  into  action,  with  this 
addition,  that  when  the  movement  is  performed  with  both  feet 


GYMNASTIC   MOVEMENTS  n 

the  lower  legs  of  the  patient  are  not  fixed  so  completely ;  thus  the 
patient  has  to  keep  his  knees  straight.  There  is  a  great  tendency 
for  flexion  to  occur  in  the  knees  during  the  last  stage  of  the  foot 
flexion,  owing  to  increasing  tension  in  the  gastrocnemius,  and 
the  quadriceps  cruris  has  to  work  hard  to  counter-balance  this. 

Standing  Double  Heel  Raising,  PA. 

This  has  virtually  been  described  under  toe  standing  double 
knee  bending  (p.  66)  ;    it  is,  however,  sometimes  prescribed  by 


itself.  The  patient  rises  slowly  on  his  toes  as  high  as  possible 
to  toe  standing  position,  and  then  executes  the  reverse  move- 
ment. The  effect  of  the  exercise  may  be  doubled  by  keeping  one 
foot  passive,  using  only  the  other  to  do  the  raising.  In  either 
case  the  arms  may  be  placed  in  reach  lean  or  reach  grasp  posi- 
tion, for  the  sake  of  balance. 

The  extensors  of  the  ankles,  including  the  gastrocnemius  (see 
p.  66)  and  many  of  the  plantar  muscles  (which  serve  to  maintain 
the  arches  of  the  foot)  are  exercised.^ 


Standing  Alternate  Foot  Flexion  and  Extension,   PA. 

From  the  standing  position  the  patient,  keeping  his  heel  on 
the  ground,  first  flexes  the  ankle-joint  as  far  as  it  will  go,  and 
then  extends  it   until  the  sole  of  the   foot   again   rests   on   the 

'  Cf.  Hj.  Ling  "  De  Forsta  Begreppen  af  Rorelseluran,"  18G6,  pp.  184,  199,  206. 


72     ELEMENTS   OF   KELLGREN'S   MANUAL   TREATMENT 

ground  ;  he  then  does  the  same  with  the  other  foot.  The  pro- 
cess should  be  repeated  several  times. 

The  flexors  of  the  ankles  and  extensors  of  the  toes  are  at  first 
in  concentric,  then  in  excentric  contraction.  The  higher  the 
flexion  proceeds,  the  harder  the  extensors  of  the  knees  have  to 
work  in  order  to  counteract  the  increasing  tension  in  the  gastroc- 
nemius, just  as  in  the  case  of  half  lying  double  foot  flexion,  AR 
(see  p.  71). 

A  variety  of  foot  flexion  is  as  follows : — The  thigh  lies 
horizontally  and  is  fixed ;  the  lower  leg  hangs  by  its  own  weight 
(the  knee-joint  being  thus  flexed  to  a  right  angle)  ;  the  leg  is 
at  such  a  height  that  in  this  position  the  toes  do  not  touch  the 
ground.  If  the  movements  of  foot  extension  and  flexion  be  then 
executed,  it  will  be  seen  that  during  the  first  there  is  no  con- 
traction in  the  gastrocnemius,  soleus  or  plantaris.  According  to 
Hj.  Ling  the  movement  is  accomplished  only  by  the  tibialis 
posticus  and  peronei,  and  in  this  particular  case  the  foot  is  no 
longer  a  lever  of  the  first  order  as  it  is  in  all  other  exercises.' 

(4)     Of  the   Othep  Joints   of  the    Foot  and   Toes. 

Flexion  or  extension  may  be  given,  if  so  desired,  at  any  of  the 
above  joints  that  permit  of  these  movements.  The  bone  imme- 
diately above  the  articulation  it  is  desired  to  affect  is  fixed  by  one 
of  the  assistant's  hands,  the  other  hand  being  employed  to  apply 
traction,  and  also,  in  the  case  of  duplicate  movements,  the  neces- 
sary resistance,  at  the  bone  immediately  below. 

The  flexors  and  extensors  respectively  of  the  joint  manipulated 
are  exercised. 

III. — Flexion  and  Extension  of  the  Head. 
(1)     Flexion    Forwards  and    Extension    Backwards. 

Reach  Grasp   Standing  Head  Flexion,  PR,  Extension,  AR. 

(Also  called  neck  bending  and  stretching.) 

This  exercise  can  be  administered  in  one  of  two  ways,  the 
more  common  being  as  follows : — («)  The  patient  assumes  the 
reach  grasp  standing  position  ;    the  assistant  places  both  hands 

'  "  De  Fiirsta  Begreppen  af  Ruielseliiran,"  1866,  p.  184. 


GYMNASTIC    MOVEMENTS  jt, 

on  the  patient's  bead  so  that  his  thumbs  he  under  the  superior 
curved  hnes  of  the  occipital  bone,  and  the  fingers,  somewhat 
spread  out,  rest  against  the  lateral  parts  of  the  skull.  Then, 
continually  lifting  the  head  upwards,  the  assistant  flexes  it  for- 
ward with  resistance  from  the  patient,  who  at  the  same  time 
keeps  his  cervical  vertebrae  immovable  and  draws  in  his  chin. 
By  performing  the  exercise  in  this  manner,  the  actual  movement 
that  takes  place  is  confined  to  the  occipito-atlantal  joint.  The 
reverse  movement  is  then  executed  with  AR  (fig.  28). 

The  circulation  through  the  brain  is  hastened,  this  being  due 
to  the  alternate  elongation  and  shortening  of  the  vertebral  vessels, 
carotid   arteries   and   internal    jugular  veins.     The  flow    in   the 


latter  is  especially  furthered  because  of  the  attachment  of  their 
walls  to  the  sterno-mastoids,  alternate  shortening  and  elongation 
of  which  alternately  decrease  and  increase  the  lumen  of  the 
vessels  (see  p.  48).  The  muscles  placed  in  action  are  tlio 
extensors  both  of  the  cervical  vertebrge  and  of  the  occipital 
bone,  some  of  them  being  maintained  in  a  constant  attitude  in 
order  to  fix  the  cervical  vertebrae,  while  others  are  first  excen- 
trically  and  then  concentrically  contracted  in  order  to  execute 
the  movements  at  the  occipito-atlantal  joint.  In  consequence  of 
their  activity,  they  become  more  fully  supplied  with  blood,  and 
thus  act  depletingly  on  the  brain. 

(6)  If  abnormal  curvatures  forwards  in  the  cervical  vertebree, 
such  as  are  found  in  cases  of  paralysis  agitans,  &c.,  have  to  be 


74     ELEMENTS    OF   KELLGREN'S   MANUAL    TREATMENT 

dealt  with,  the  movement  is  performed  iii  rather  a  different 
manner  from  that  just  described ;  the  cervical  vertebra,  instead 
of  being  kept  rigid,  are  allowed  to  participate  in  the  movement. 

When  the  exercise  is  achieved  in  the  second  manner,  the 
vessels  are  not  subjected  to  such  an  amount  of  alternate  elonga- 
tion and  shortening  as  when  the  cervical  vertebrte  are  kept 
immovable.  The  weakened  posterior  muscles,  ligaments,  fasciae, 
kc,  of  the  cervical  part  of  the  spinal  column  are  specially 
affected. 

It  the  movement  be  carried  out  in  the  opposite  direction,  i.e., 
first  extension  backwards  with  AE,  and  then  the  reverse  with 


PR,  the  chin  not  being  drawn  in,  a  tendency  towards  congestion 
of  the  head  results.     This  is  because  :  — 

(1)  The  hyoid  bone  is  elevated  ;  thus  there  is  a  reversal  of 
the  function  of  the  omo-hyoid  muscle,  which  normally  acts  con- 
tmuously  in  keeping  the  walls  of  the  internal  jugular  vein  open, 
but  which  will  now  exert  continuous  pressure  on  the  vein,  and 
cause  diminution  in  its  lumen  and  in  the  volume  of  its  blood  flow. 

(2)  The  sterno-mastoid  is  stretched,  which  under  ordinary 
circumstances  would  open  out  the  internal  jugular  vein ;  but  as 
the  cervical  vertebrae  are  extended  on  themselves,  the  vein  will 


GYMNASTIC   MOVEMENTS  75 

be  caught  between  them  and  the  sterno-mastoid,  and  suffer  con- 
tinuous pressure. 

Head  flexion,  PE,  extension,  AE,  va&y  also  be  administered 
from  other  initial  positions,  such  as  hips  firm  arch  forwards 
lying.  The  assistant's  grasp  is  different  from  the  one  used  when 
the  movement  is  given  from  reach  grasp  standing  position ;  and 
will  be  most  easily  understood  from  the  illustration  (fig.  29).  In 
this  case  the  muscles  called  into  action  are  the  erectors  of  the 
spine,  which  have  to  keep  the  patient  in  arch  position,  and  the 
cervical  extensors  (as  mentioned  on  p.  73). 


(2)     Other  Varieties  of  Head   Flexion  and   Extension. 

(1)  Head  flexion  laterally,  AK  (and  the  reverse  movement, 
PR),  is  used  to  exercise  the  sterno-mastoid,  complexus,  trapezius, 
&c.,  of  one  side  (fig.  30). 

(2)  A  combined  movement  of  extension,  lateral  flexion,  and 
rotation  may  be  employed  in  order  to  exercise  one  sterno-mastoid. 
Suppose  it  necessary  to  deal  with  a  case  where  there  is  con- 
traction in  that  muscle  of  the  left  side.  The  appropriate  treat- 
ment will  be  to  exercise  its  weakened  antagonist  bj'  so  placing 
the  head  that  it  has  a  chance  of  contracting  ;  and  in  the  course 
of  time,  if  it  be  exercised  sufficiently,  it  will  by  its  physiological 
pull  correct  the  deformity  by  removing  the  contraction  and  restor- 
ing equilibrium  between  the  two  muscles.     In  order  to  effect  this 


76     ELEMENTS    OF   KELLGREN'S    MANUAL    TREATMENT 

the  head  is  Hexed  more  to  the  left,  extended  still  further  back- 
wards, and  rotated  yet  more  to  the  right,  with  PR  ;  the  reverse 
is  then  executed  with  AK.  Thus  the  weakened  sterno-mastoid 
is  exercised  at  the  expense  of  the  contracted  one  '  (fig.  31). 

To  try  and  forcibly  stretch  the  contracted  muscle  without 
exercising  its  antagonist  will  do  no  good,  as  this  results  in 
simply  stimulating  the  former,  and  thus  tending  to  increase  the 
deformity. 


IV. — Flexion  and  Extension  of  the  Trunk. 

There  are  four  kinds : — (1)  Flexion  and  extension  of  the 
trunk  on  the  hip-joints  (the  vertebral  column  remaining  immov- 
able). (2)  Flexion  and  extension  of  the  trunk  on  itself  {i.e.,  the 
movement  is  confined  to  the  vertebral  column,  the  hip-joints  not 
participating).  (3)  A  combination  of  the  above  two.  (4)  Lateral 
Hexion  and  extension  of  the  trunk  on  itself  {i.e.,  the  move- 
ment is  confined  to  the  vertebral  column,  the  hip-joints  not 
participating). 

Examples  of  the  above  trunk  movements  occur  in  many 
exercises,  and  the  terms  flexion  and  extension  (or  bending  and 
stretching)  have  been  applied  to  some  of  them.     They  will  now 

'  The  principle  already  advocated  by  P.  H.  Ling,  ou  which  rests  the  administra- 
tion of  the  above  movements,  is  the  fundamental  cue  for  the  treatment  of  all 
deformities.     {Cf.  "  Gymnastikens  Allmanna  Grunder"  (1834),  1840,  p.  189.) 


GYMNASTIC   MOVEMENTS^  yy 

be  fully  described.  Tbere  are,  however,  many  others,  called  by 
other  names,  such  as  drawing  backwards,  &c. ;  these  will  be  dealt 
with  later  under  their  respective  headings. 

(1)    Flexion  and   Extension  of  the  Trunk  on  the  Hip-joints. 

Ride  Sitting  Trunk  Flexion,  PR,  Extension,  AR. 

The  patient  assumes  the  ride  sitting  position  with  hips  firm 
and  back  as  straight  as  possible.  The  assistant  places  'one 
hand   under   the   patient's    occiput,    as   in   the   figure,    and   the 


other  hand  on  the  patient's  thigh,  in  order  to  steady  him. 
Keeping  up  traction  away  from  the  hips,  the  hand  under  the 
occiput  presses  the  latter  forwards  and  downwards,  the  patient 
continually  resisting  and  keeping  his  head  erect  and  his  spinal 
column  quite  straight.  Thus  flexion  of  the  trunk  on  the  hip- 
joints  takes  place,  and  this  is  continued  through  an  angle  of  about 
75°,  whereupon  the  reverse  movement  is  executed,  with  AE 
(fig.  32).  This  movement  may  also  be  performed  from  leg  lean 
stride  standing  position  (with  hips  firm). 


78     ELEMENTS   OF    KELLGREN'S   MANUAL    TREATMENT 

The  extensors  of  the  thighs  are  first  excentrically  and  then 
concentrically  contracted  ;  the  spinal  extensors  from  sacrum  to 
occiput  are  also  placed  vigorously  in  action,  and  undergo  greater 
stress  as  flexion  proceeds ;  during  extension  the  extra  strain 
on  them  is  gradually  removed.  In  consequence  of  this  and  of 
the  fact  that  the  patient  has  to  keep  his  back  as  straight  as 
possible,  the  exercise  tends  to  correct  any  abnormal  curvatures 
and  rotations  that  may  exist  in  the  spinal  column.  It  may  here 
be  added  that  all  movements  in  which  the  patient  has  actively 
to  try  and  straighten  his  spine  tend  to  correct  such  deformities, 
as  they  entail  the  patient  making  efforts  to  contract  the  weakened 
muscles  at  the  expense  of  the  too  strong  antagonists  (c/.  pp.  75,  76). 

Effect  on  the  abdomen.— The  abdomen  is  subjected  at  first 
to  an  increase  of  pressure,  and  then  to  a  correspondmg  decrease. 
The  precise  effect  of  this  will  be  considered  on  p.  83. 

Falling. 

By  falling  is  meant,  unless  otherwise  specified,  a  falling  for- 
wards, during  which  the  lower  limbs  and  trunk  move  as  a  whole. 
This  has  been  described  already  (p.  52). 

Falling  backwards  occiirs  in  the  following  : 

Bide  Fall  Sitting  Breathing,  PA. 

The  patient  assumes  the  ride  sitting  position,  usually  with 
hips  firm  (see  p.  79),  and  then  lets  his  trunk  fall  backwards  by 
means  of  extension  at  the  hip-joints,  until  ride  fall  sitting  posi- 
tion is  reached.  He  remains  in  this  position  long  enough  to 
respire  deeply  three  times,  and  then  raises  the  trunk  to  the 
original  position  again  (fig.  33). 

The  flexors  of  the  hip-joint  perform  the  movement,  which 
entails  a  powerful  stress  on  the  spinal  and  abdominal  muscles, 
and  is  of  special  benefit  to  the  latter.  Powerful  action  of  the 
anterior  abdominal  muscles  in  all  probability  reflexly  stimulates 
the  abdominal  contents  (see  p.  61).  (Further  particulars  as  to  the 
active  muscles  can  be  found  on  p.  59.)  The  respiratory  organs 
are  also  benefited.  During  the  progress  of  this  exercise,  proper 
respiration  is  of  the  strongest  importance,  otherwise  great  engorge- 
ment of  the  veins  arises  in  a  very  few  seconds.' 

'  Cf.  Hj.  Ling  in  Branting's  "  Efterlemnade  Skrifter,"  1882,  pp.  xxi.,  xxiii. 


GYMNASTIC   MOVEMENTS  79 

Sitting  Trunk  Extension  and   Flexion,   PA. 

(Also  called  sit  lying  back  raising). 

From  the  sitting  position  with  hips  firm  (see  below)  and 
the  lower  legs  fixed,  the  patient,  keeping  his  head  erect  and 
his  spine  as  straight  as  possible,  slowly  falls  backwards,  i.e., 
he  allows  extension  of  the  trunk  on  the  hip-joints  to  take  place, 
until  sit  lying  position  is  reached.  The  reverse  movement  is  then 
executed. 

The  flexors  of  the  hip-joints  are  first  in  excentric,  then  in  con- 
centric contraction,  and  the  anterior  abdominal  and  erector  spinae 


muscles  have  to  work  hard  in  order  to  keep  the  trunk  straight. 
The  effect  of  the  exercise  is  very  similar  to  that  of  lying  double 
leg  flexion  and  extension,  PA  (p.  61).  It  can  be  increased  by 
keeping  the  patient's  arms  in  neck  firm  position ;  or,  what 
entails  even  greater  effort,  in  stretch  position.  Other  exercises 
such  as  ride  fall  sitting  breathing,  PA  (see  p.  78),  can  also  be 
graduated  in  a  similar  manner. 

The  exercise  can  also  be  rendered  more  difficult  of  execution 


So     ELEMENTS    OF   KELLGREN'S    MANUAL   TREATMENT 

by  only  fixing  the  upp(>r  legs,  as  thereby  the  lower  part  of  the 
quadriceps  cruris  is  thrown  out  of  action. 

(2)  Flexion  and   Extension  of  the  Trunk  on   Itself. 
Forwards  Lying  Back  Raising  (Arching)  Breathing,  PA. 

The  patient  assumes  the  forwards  lying  position.  The 
assistant  fixes  the  patient's  feet  and  exercises  traction  on  them 
away  from  the  trunk.  Placing  his  arm  into  hips  firm  position, 
the  patient  then  brings  himself  into  arch  forwards  lying  position, 
and  remaining  thus,  breathes  deeply  three  times  (fig.  34).      The 


effect  of  this   exercise  may   be  increased   by  putting    the    arms 
into  neck  firm,  or  even  in  stretch  position  (see  p.  79). 

The  extensors  of  the  spinal  column  and  thighs  are  in  action. 
This  movement  is  also  a  respiratoi'y  exercise. 

Head  Lean  Arch  Standing  Toe  Raising,  Breathing,  PA. 

The  patient  assumes  the   head   lean   arch  standing  position 
with  hips  firm.     He  then  rises  on  his  toes,  but  keeps  his  head  at 


GYMNASTIC    MOVEMENTS  8i 

the  same  level  as  at  first,  after  which  he  sinks  down  on  his 
heels,  on  this  occasion  letting  body  and  head  move  together ;  the 
net  result  is  to  leave  the  spinal  column  more  arched  than  before. 
The  process  is  repeated  three  times ;  each  time  the  patient's 
head  descends,  and  each  time  his  spinal  column  becomes  more 
and  more  arched  in  the  dorsal  region,  while  his  chest  is  brought 
out  more  prominently  (fig.  35).  Deep  inspiration  should  take 
place  during  the  rising  on  the  toes,  deep  expiration  during  the 


reverse.  After  the  third  repetition  the  patient  straightens  him- 
self up  to  hips  firm  standing  position. 

When  patients  are  unable  to  perform  this  exercise  without 
the  spine  becoming  lordosed  during  its  execution,  the  position  of 
the  head  may  be  left  constant  instead  of  being  allowed  to  change 
with  each  sinking  on  the  heels. 

The  muscles  affected  are  brought  into  use  in  the  following 
manner : — During  the  first  part  of  the  exercise,  in  order  to  bring 
the  patient  into  arch  position,  there  takes  place  : — a  slight  con- 
centric contraction  of  the  erector  spinas  muscles  with  elongation 
G 


82     ELEMENTS  OF  KELLGREN'S  MANUAL    TREATMENT 

of  the  anterior  abdoiuiiial  muscles.  This  is  ahnost  immediately 
replaced  by  aa  excentric  contraction  of  the  anterior  abdominal 
muscles,  to  counteract  the  pull  of  gravity,  with  passive  shortening 
of  the  erector  spinae.  Elongation  of  the  anterior  abdominal 
muscles  in  consequence  of  recommencing  concentric  contraction 
of  the  erector  spina;  then  takes  place.  During  the  second 
part  of  the  movement  {i.e.,  during  the  toe  raising),  the  erector 
muscles  of  the  spine  and  extensors  of  the  ankle-joint  are  in 
action.  The  return  to  the  original  position  is  effected  through 
concentric  contraction  of  the  anterior  abdominal  muscles  {cf.  Hj. 
Ling'). 

This  movement  is   very  useful  in  disorders    of   coordination, 
(see  p.  68);  it  is  also  a  chest  expanding  exercise  (see  p.  124  . 


(3)  Flexion  and  Extension  of  the  Trunk  on  the  Hip-joints, 
combined  with  Flexion  and  Extension  of  the  Trunk 
on    Itself. 

Stretch  Stride  Standing  Bending  Forwards,  PA. 

Tlie  patient  assumes  the  stretch  stride  standing  position, 
(fig.  7,  p.  18),  stretched  to  his  utmost  with  the  abdomen  well 
drawn  in  (this  latter  is  very  important  in  the  case  of  a  patient 
suffering  from  pelvic  disease  or  hernia  through  the  anterior 
abdominal  wall).     He  then  proceeds  as  follows  : — 

(1)  He  flexes  his  trunk  on  his  hips  as  in  ride  sitting  trunk 
flexion  (p.  77).  In  order  to  preserve  the  balance  the  pelvis  must 
meanwhile  be  carried  somewhat  backwards.  (2)  Having  executed 
this  movement  as  far  as  possible  without  bending  the  knees,  he 
flexes  the  spinal  column  on  itself,  the  flexion  commencing  in 
the  upper  dorsal  region  and  gradually  passing  downwards.  The 
arms,  however,  are  throughout  to  be  kept  as  far  back  as  possible. 

(3)  When  this  has  been   carried   out    to   the   utmost   limit,    he 
executes  the  reverse  of  (2),  still  keeping  the  knees  quite  straight. 

(4)  Fmally  he  executes  the  reverse  of  (1),  so  as  once  more    to 
reach  the  initial  position. 

This  division  into  parts  is  merely  for  the  sake  of  clearness  of 
description ;  in  practice  the  exercise  should  be  performed  evenly 

'   "De  Pcji-sta  Begreppen  af  Riirelseliiran,"  J866,  pp.  21G,  217. 


GYMNASTIC    MOVEMENTS  83 

and  continuously,  the  parts  merginf;  into  one  another  without 
a  break. 

The  actual  movement  is  initiated  by  a  concentric  contraction 
of  the  anterior  abdominal  muscles  and  flexors  of  the  hip-joint, 
with  elongation  of  the  extensors  of  the  hip-joint.  This  is 
almost  immediately  replaced  by  excentric  contraction  of  the  latter, 
to  counteract  the  pull  of  gravity.  When  that  stage  of  the 
movement  is  reached  where  the  spinal  column  is  flexed  on  itself, 
there  takes  place  excentric  contraction  of  the  erector  spinse,  aided 
at  the  very  termination  of  this  stage  by  recommencing  concentric 
contraction  of  the  anterior  abdominal  muscles  and  flexors  of  the 
hip-joint.  The  reverse  movement  is  then  efl'ected  by  concentric 
contraction  in  the  erector  spinse  and  extensors  of  the  hip-joint. 

The  flexors  of  the  ankles  are  first  excentrically  and  then  con- 
centrically contracted.  The  extensors  of  the  knees  have  to  work 
hard  in  order  to  maintain  the  straightness  of  the  knees  against 
the  pull  of  the  hamstrings.  Many  of  the  other  muscles  of  the 
leg  are  active  in  order  to  maintain  equilibrium. 

Effect  on  the  abdominal  contents. — In  consequence  of  the 
alternate  application  and  removal  of  pressure  and  of  the  alternate 
elongation  and  shortening  of  many  of  the  abdominal  blood  and 
lymph  vessels,  the  whole  of  the  abdominal  contents  are  stimu- 
lated, and  the  venous  and  lymphatic  return  from  them  promoted. 
For  the  same  reasons  the  flow  in  the  thoracic  duct  and  inferior 
vena  cava  will  be  hastened,  as  these  structures  lie  against  the 
vertebral  column  and  closely  follow  all  its  movements.  Thus  the 
venous  return  from  the  legs  will  be  influenced  as  well  as  that 
from  the  splanchnic  area  (cf.  P.  H.  Ling,'  Georgii,^  Hj.  Ling,^ 
Loven,''  Braune'). 

Effect  on  the  thorax. — The  blood-vessels  and  lymphatics  of 
the  intercostal  spaces  will  be  alternately  subjected  to  and  relieved 
from  pressure,  and  thus  their  venous  and  lymphatic  circulation 
will  be  promoted.  The  latter  is  aided  by  the  fact  that  the  lym- 
phatics of  these  spaces  are  arranged  in  two  sets  just  as  in  all  the 


'  "  Gymnastikens  AUmiinna  Grunder"  (1834),  1840,  p.  143. 
-  "  Kinetic  Jottiugs,"  1880,  pp.  112,  113. 
5  "  Porkortad  Ofversigt  af  AUman  Rorelseliira,"  1880,  p.  54. 
'  "  Om  Blodet,"  1876,  pp.  59,  60. 

'  "Beitrag  zur  Kenntniss  der  Venenelastioitiit,"  pp.  ii.  aud  v.,  in  "  Beitrage  zur 
Anatomie  und  Physiologie,  Festgabe  fiir  G.  Ludwig,"  1874. 


84     ELEMENTS   OF   KELLGREN'S    MANUAL    TREATMENT 

tendons  and  aponeuroses  of  the  body  '  (see  p.  27).     The  lungs  are 
alternately  diminished  and  increased  in  volume. 

Effect  on  the  spinal  cord  and  size  of  the  spinal  canal. — First 
elongation  and  then  shortening  of  the  spinal  cord^  and  its  longi- 
tudinal veins  take  place ;  the  spinal  cord  will  be  stimulated,  and 
the  flow  in  the  veins  hastened.  The  capacity  of  the  spinal  canal 
is  probably  first  slightlj'  diminished  and  then  increased.' 


(4)  Lateral   Flexion  and   Extension  of  the  Trunk  on  Itself. 

Stretch  Stride  Standing  Bending  Sideways,  PA. 

The  patient  assumes  the  stretch  stride  standing  position, 
stretched  to  his  utmost.  He  then  flexes  his  trunk  laterally  to 
side  bend  position,  stretching  especially  the  arm  of  the  elongated 
side,  keeping  his  lower  limbs  and  pelvis  as  still  as  possible. 
No  rotation  of  the  vertebrae  should  take  place,  i.e.,  there  should 
be  no  protrusion  of  either  shoulder  or  hip.  The  reverse  move- 
ment is  then  executed,  thus  bringing  the  patient  back  into  the 
initial  position,  after  which  the  whole  process  is  repeated  towards 
the  other  side  (fig.  36). 

Respecting  the  muscles  that  are  in  action  in  this  movement : — 
Suppose  the  patient  to  perform  the  exercise  towards  the  left 
side.  At  first  the  left  lateral  flexors  of  the  trunk  contract 
concentrically  to  a  very  small  amount  ;  immediately  after  this 
they  undergo  a  passive  shortening,  this  being  due  to  excentric 
contraction  of  the  right  lateral  flexors,  to  counteract  the  pull  of 
gravity.  When  the  latter  are  incapable  of  further  excentric 
contraction  they  become  elongated,   in    consequence  of   recom- 

'  Dybkowski,  "  Uber  Aufsaugung  und  Ab-sonderung  der  Pleurawand,"  in  Arbeiten 
an  der  Phys.  Anat.  zu  Leipzig,  1866,  pp.  40-67. 

-  See  Hegar,  "Die  Ruckenmarksdeiinuug,"  in  Sammlung  Klinischer  Tortragc, 
1884,  No.  239  ;  Gyncikologie,  No.  65,  pp.  1699-1714.  Tourette  and  Chipault, 
"  Le  traitement  de  I'ataxie  par  I'eloDgation  vraie  de  la  moelle  ^pini&re,"  in 
Nouvelle  Iconographie  de  la  Salpetiire,  1897,  vol.  x.,  pp.  145-154.  Tourette  and 
Gasne,  "Le  traitement  de  I'ataxie  locomotrice  par  I'^longation  vraie  de  la  moelle 
epini^re,"  ibid.,  1898,  vol.  xi.,  pp.  18,  19.  P.  H.  Ling  refers  to  exercises  on  the 
spinal  cord  in  "  Gymnastikens  AUmiinna  Grander"  (1834),  1840,  p.  158.  C/.  Neu- 
mann, "  Lebrbucii  der  Leibesiibungen  des  Menschen,"  1856,  part  ii.,  pp.  136,  &c. 
Hj.  Ling,  "  Forkortad  Ofversigt  a£  Allmiin  Rorelselara,"  1880,  p.  54. 

'  Reid  and  Sherrington,  "  The  Effect  of  Movements  of  the  Human  Body  on  the 
size  of  the  Spinal  Canal,"  Brain,  vol.  xiii.,  1890,  pp.  449-455. 


GYMNASTIC    MOVEMENTS 


85 


mencing  concentric  contraction  of  the  left  lateral  flexors,  which 
continue  to  contract  until  the  right  side  of  the  trunk  cannot  be 
elongated  any  more.  The  right  lateral  flexors  then  perform  the 
reverse  movement. 

The  effect  on  the  abdomen  is  the  same  as  in  the  case  of  the 
last  exercise.  The  circulation  in  the  inferior  vena  cava  and  the 
lower  two  azygos  veins  is  hastened,  as  is  also  the  venous  and 
lymph   flow  from  the  intercostal  spaces  and  the  pleura.     There 


will   be  alternately  an  increase  in  the  size  of  one  lung,  coupled 
with  a  decrease  in  the  size  of  the  other,  and  then  the  reverse. 

Effect  on  the  spinal  cord. — All  lateral  trunk  movements 
produce  elongation  of  one  side  of  the  cord  and  shortening  of  the 
other,  though  whether  this  is  sufficient  to  cause  an  appreciable 
stimulation  has  as  yet  not  been  experimentally  demonstrated. 


86     ELEMEXTS    OF   KELLGREN'S    MANUAL    TREATMENT 

Hip  Lean  Walk  Standing  Lateral  Flexion,  PP,  Extension,^R. 

The  patient  assumes  the  hip  lean  walk  standing  position 
with  neck  firm.  The  assistant  grasps  the  patient  round  the 
elbows,  and,  while  keeping  up  traction  away  from  the  pelvis, 
flexes  his  trunk  laterally  over  the  bar  into  side  bend  position. 
The  reverse  movement  is  then  executed  with  AE  applied  at  the 


elbow  of  the  extended  side,  the  assistant's  other  hand  being  only 
used  to  steady  the  patient  (fig.  37). 

The  muscles  placed  in  action  are  the  lateral  flexors  of  the 
trunk  on  the  side  remote  from  the  support,  which  are  first 
passively  elongated  and  then  concentrically  contracted.  The 
effect  of  this  movement  on  the  abdomen  and  thorax  is  the  same 
as  in  the  case  of  the  last  exercise. 


GYMNASTIC   MOVEMENTS  87 

Ringing.' 

This  is  a  passive  form  of  movement,  consisting  in  a  rapid 
alternating  flexion  and  extension.  The  use  of  the  v?ord,  how- 
ever, is  very  restricted. 

Loin  Lean  Stride  Standing  Ringing,  PP. 

The  patient  assumes  the  loin  lean  stride  standing  position, 
with  the  arms  in  neck  firm  position.     The  assistant  applies  his 


grasp  under  the  patient's  elbows,  and  keeping  up  traction  away 
from  the  pelvis,  flexes  the  patient's  trunk  to  one  side  (say  the 
left)   into   left    side   bend  position,  then   right    over  through  the 


'  This  is  a  literal  translation  of  the  Swedish  word  "  ringning,"  and  though  not 
bearing  quite  the  same  meaning,  is  yet  the  nearest  English  equivalent  possible. 


88      ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

original  to  right  side  bend  position,  and  back  again.  Altogether 
the  process  is  repeated  six  or  eight  times  fairly  quickly,  the 
patient  returning  at  the  close  into  the  initial  position  (fig.  38). 
This  movement  may  l^e  performed  from  other  initial  positions, 
such  as  ride  sitting  or  loin  lean  stride  kneeling. 

The  effects  on  the  abdomen  and  thorax  are  similar  to  those 
in  the  case  of  the  last  exercise.  The  lateral  flexors  of  the  trunk 
are  alternately  passively  elongated  and  shortened. 

Exercises  which,  like  the  above,  consist  in  a  passive  alter- 
nating flexion  and  extension  of  the  trunk,  have  always  been 
regarded  by  the  Ling  school  as  having  a  sedative  effect  on  the 
brain,  and  thus  tending  to  remove  insomnia.' 

[The  term  ringing  has  also  been  applied  to  sit  lymg  knee 
extension  and  flexion,  PP  (see  p.  68).] 


'  Cf.   Hartelius,   "  Larobok  i   Sjuligjmnastik,"   ISVO,   p.    106  ;    1S83,  p. 
1892,  p.  109. 


109 


GYMNASTIC   MOVEMENTS 


ABDUCTION  AND  ADDUCTION. 

(1)    Of  the    Shoulder-joint. 

Modern  anatomists  are  still  somewhat  at  variance  regarding 
the  mechanism  of  these  movements.  It  used  to  be  laid  down 
that  the  first  half  of  the  movement  up  to  the  horizontal  was 
accomplished  by  movement  at  the  gleno-humeral  joint,  the  scapula 
being  fixed,  and  that  the  second  half  depended  solely  on  rotation  of 
the  scapula.  This  explanation,  however,  is  manifestly  incorrect ; 
it  implies  that  the  scapula  would  rotate  through  an  angle  of  90", 
so  that  at  the  conclusion  of  the  movement  its  vertebral  border 
would  be  horizontal,  which  is  contrary  to  what  actually  obtains. 
At  a  later  period  certain  observers  stated  that  the  scapula 
rotated  most  during  the  first  half  of  the  movement  and  least 
during  the  last  quarter.^ 

As  a  matter  of  fact  there  are  two  methods  of  performing  the 
movements  of  abduction  and  adduction  of  the  shoulder,  just  as  in 
the  case  of  flexion  and  extension  of  that  joint : — 

(i)  As  during  every-day  life,  the  scapula  not  being  fixed. 

(ii)  As  during  gymnastic  exercises,  the  scapula  being  kept 
drawn  inwards  and  backwards. 

In  the  former  of  these  two  cases  the  facts  are  as  stated  by 
the  authors  just  referred  to  ;  in  the  latter  the  details  are  as 
follows : — 

(a)  During  the  first  part  of  the  abduction  up  to  yard  position. 

The  scapula  remains  immovable,  and  the  movement  takes  place 

only  at  the  gleno-humeral  joint. 

(b)    During   the  second   part  of  the   abduction  up  to  stretch 

position.     At  first  the  movement  is  effected  almost  exclusively  by 

'  See,  for  example,  Cathcart,  "  Movements  of  the  Shoulder-girdle  involved  in 
those  o£  the  Arm  on  the  Trunk,"  in  Journ.  of  Anat.  and  Phys.,  1884,  vol.  xviii., 
pp.  211,  &e.  Cleland,  "Notes  on  Raising  the  Arm,"  ibid.,  p.  275.  Cleland  and 
Mackay,  "  Human  Anatomy,''  1896,  pp.  155  and  267.  Dalla  Kosa,  "  Physiologische 
Anatomie  des  Menscheu,"  1898,  vol.  i.,  p.  283.  Mollier,  "  Uber  die  Statik  uud 
Mekauik  des  meusohliehen  Schultergiirtels  unter  uormalen  und  pathologischen 
Verbaltnissen,"  1899.  Steinhausen,  "  Beitrage  zur  Lehre  von  dem  Mechanismus 
der  Bewegungen  des  Schultergiirtels,"  in  Archiv.  f.  Anat.  u.  Phys.,  Physiol.  Abth., 
Suppl.  End.,  1899,  pp.  403,  &c.  Gray,  "  .\natomy.  Descriptive  and  Surgical," 
1901,  p.  235. 


90     ELEMENTS   OF   KELLGREN'S   MANUAL    TREATMENT 

rotation  of  the  scapula,  the  gleno-humeral  joint  participating  very 
shghtly  indeed.  Then  the  scapula  rotates  less  and  less  in  pro- 
portion to  the  movement  at  the  gleno-humeral  joint,  the  final 
stage  being  effected  almost  exclusively  by  movement  at  the 
latter. 

During  the  reverse  movements  the  reverse  takes  place.' 
The  reasons  for  keeping  the  scapula  draw^n  inwards  and  back- 
wards are  the  same  as  those  given  on  pp.  45,  46. 


The  amount  of  internal  rotation  of  the  humerus  that  is  present 
in  the  original  position  {i.e.,  where  the  arm  is  hanging  vertically 
downward)  will,  if  kept  constant,  render  it  impossible  for  the  arm 
to  be  fully  abducted.  A  certain  amount  of  external  rotation  of 
the  humerus  must  take  place  in  order  to  enable  the  arm  to  be 
brought  into  stretch  position. 

From  the  standpoint  of  medical  gymnastics  the  movements  of 

'  Cf.  Hj.  Ling,  "  De  Piirsta  Begreppen  af  R5relselaran,"  1866,  pp.  206,  229,  230. 


GYMNASTIC    MOVEMEXTS  91 

abduction  aud  adduction  of  the  shoulder-joint  may  be  divided  into 
two  classes  :  (a)  without  co-movement  of  the  elbow-joint ;  (6)  with 
co-movement  of  the  elbow-joint.  Two  examples  of  each  will  be 
described. 

Ride  Sitting  Double  Arm  Abduction,  AR,  Adduction,  PR. 

The  patient  assumes  the  ride  sitting  position ;  the  assistant 
grasping  the  patient's  wrists,  performs  traction  away  from  the 
shoulder  and  resists  while  the  patient  abducts  his  arms  through 
yard  position  (with  the  palms  of  his  hands  looking  directly  for- 
wards) up  to  stretch  position  (where  the  palms  should  look 
directly  towards  each  other).  The  reverse  movement  is  then 
executed,  generally  with  PE,  although  it  may  be  given  with  AR 
(fig.  39). 

Alternate  abduction  and  adduction  of  the  shoulder-jouit  takes 
place  with  a  certain  amount,  respectively,  of  external  and  internal 
rotation  of  that  joint  and  supination  and  pronation  of  the  radio- 
ulnar joints.  If  the  movement  be  executed  as  above,  the  abductors 
are  exercised,  but  if  executed  as  abduction  AR,  adduction  AR, 
then  first  the  abductors  and  then  the  adductors  are  brought  into 
play.  The  chest  alternately  increases  and  decreases  in  size.  The 
effect  on  the  venous  and  lymph  flow  is  practically  the  same  as  in 
the  case  of  arm  raising  (pp.  48,  49). 

Swim  Sitting  Double  Elbow  Pressing  Downwards,  PR, 
Upwards,  AR. 

The  patient  assumes  the  swim  sitting  position  ;  the  assistant 
keeping  up  traction  away  from  the  shoulders,  presses  over  the 
upper  aspect  of  the  elbow-joints,  so  as  to  cause  adduction  of  the 
upper  arms  through  a  right  angle,  i.e.  until  they  lie  against  the 
sides,  the  patient  continually  resisting  and  keeping  his  elbows  well 
back.  The  reverse  movement  is  then  executed  with  AR  (fig.  40). 
Adduction  and  abduction  (but  not  rotation)  of  the  shoulder-joint 
takes  place,  the  muscles  called  into  action  being  its  abductors. 

Half  Lying  Double  Arm  Bending  and  Stretching,  AR. 

The  patient  assumes  the  stretch  half  lying  position  with  the 
palms  of  the  hands  looking  either  directly  away  from  one  another 
or  directly  forwards  (more  rarely  directly  towards  one  another). 


92     ELEMENTS    OF   KELLGREN'S    MANUAL    TREATMENT 

The  assistant  ^'rasps  the  patient's  hands  in  his  own  and  resists, 
while  the  patient,  keeping  his  upper  arms  and  forearms  in  the 
coronal  plane,  adducts  the  former  and  flexes  the  latter,  nntil  the 
maximum  of  these  movements  is  ohtained.     The  amount  of  pro- 


nation adopted  in  the  initial  position  should  be  kept  constant. 
The  reverse  movement  is  then  executed  with  AE  (fig.  41). 

During  the  bending  the  adductors  of  the  shoulders  and  the 
flexors  of  the  elbows  are  placed  in  action  ;  during  the  stretching 
their  antagonists  are  called  into  play.     With  persons  not  accus- 


GYMNASTIC    MOVEMENTS  93 

toiued  to  the  exercise,  there  is  a  tendency  for  the  pectoral  muscles 
to  draw  the  elbows  forwards,  and  this  tendency  is  greater  when 
the  forearms  are  supinated  than  when  they  are  pronated;  in  the 
latter  case  the  posterior  scapular  muscles  have  a  tendency  to  work 
harder  than  the  pectorals. 

Double  arm  bending  and  stretching,  AR,  may  be  given  from 
initial  positions  that  entail  greater  exertion,  such  as  stretch  sitting 
(with  the  back  unsupported) ,  or  stretch  arch  forwards  lying ; 
under  these  circumstances  the  erectors  of  the  spine  (in  addition 
to  the  above-mentioned  muscles)  are  especially  affected. 

Hanging  Trunk  Raising  with  the  Arms,  PA. 

The  patient  assumes  the  hanging  position,  generally  with 
the  palms  of  the  hands  looking  forwards  {i.e.,  the  forearms  are 
pronated),  although  under  certain  conditions  they  may  look  back- 
wards {i.e.,  the  forearms  are  supinated).  The  patient  raises 
himself  up  towards  the  bar  by  adducting  his  shoulder-joints  and 
flexing  his  elbows  to  the  maximum,  keeping  the  trunk  and  legs 
still.     The  reverse  movement  is  then  executed. 

The  adductors  of  the  shoulders  and  flexors  of  the  elbows  (see 
p.  50)  are  first  concentrically  and  then  excentrically  contracted. 

Abduction  and  adduction  of  the  shoulder-joint  also  enter  into 
certain  other  movements,  such  as  (1)  standing  double  arm 
stretching  outwards,  PA  (p.  53) ;  (2)  walk  standing  double  arm 
circling,  PA  (p.  130),  &c. 

(2)     Of  the  Thumb  and   Fingers. 

Abduction  and  adduction  of  the  thumb  can  be  prescribed  in 
cases  of  weakness  of  the  muscles  that  perform  these  movements. 

Abduction  and  adduction  of  the  fingers  can  be  prescribed  to 
exercise  the  interosseous  muscles ;  the  dorsal  interossei  are  called 
into  action  in  abduction,  AR,  adduction,  PR,  the  palmar  ones  in 
abduction,  PR,  adduction,  AR. 

(3)     Of  the  Hip-joint. 

Lying  Double  Leg  Abduction,  AR,  Adduction,  PR. 

From  the  lying  position  the  patient,  keeping  the  knees  fully 
extended,  separates  his  legs  (i.e.,  performs  abduction  of  the 
thighs),  while  the  assistant,  supporting  the  heels,  applies  resist- 
ance over  their  outer  aspect  with  traction  away  from  the  pelvis. 


94     ELE.VENTS   OF    KELLGRES'S   MANUAL    TREATMENT 

Adduction  is  then  executed  with  PK.    Tliis  movement  may  also 
be  executed  from  half  lying  position. 

The  abductors  of  the  hip-joint  are  exercised.  If  the  heels  are 
not  supported  by  the  assistant  then  the  patient  has  also  to  call 
into  action  the  flexors  of  the  hip-joint  and  fixators  of  the  pelvis. 

Side  Lying  Leg  Lifting,  AR,  Pressing  Down,  PR. 

The  patient  assumes  the  side  lying  position.  The  assistant 
applies  one  hand  over  the  outer  surface  of  the  ankle  of  that  leg 


which  is  uppermost ;  with  the  other  hand  he  steadies  the  hip. 
He  then  performs  traction  away  from  the  pelvis,  and  resists 
while  the  patient  abducts  his  leg  as  much  as  possible  (see 
p.  44),  after  which  the  reverse  movement  is  executed  with  PR. 
The  pelvis  must  be  kept  immovable,  otherwise  some  flexion  or 
extension  of  the  hip-joint  will  enter  into  the  movement  (fig.  42). 
The  muscles  required  to  fix  the  pelvis  and  the  abductors  of 
the  hip-joint  are  placed  in  action. 


Lying  Double  Leg  Flexion,  PA,  Abduction,  AR,  Adduction,  PR. 

The  patient   assumes   the  lying  position,  and  then  performs 
double  leg  flexion,  PA,  through  an  angle  of  about  30'.     Steadily 


GYMNASTIC    MOVEMENTS  95 

maintaining  this  degree  of  flexion,  he  separates  his  legs  as  far 
as  possible  while  the  assistant,  keeping  up  traction  away  from 
the  pelvis,  resists  over  the  outer  aspect  of  the  heel.  The 
reverse  movement  is  then  executed  with  PE  (fig.  43). 

The  flexors  and  abductors  of  the  hip-joint  and  fixators  of  the 
pelvis  are  exercised. 


Crook  Half  Lying  Double  Knee  Abduction,  AR,  Adduction,  PR. 

From  the  crook  half  Ij'ing  position  the  patient  separates  his 
knees  as  far  as  possible,  keeping  his  heels  together  all  the  time, 
with  AR  over  the  outer  side  of  the  knee-joint.  The  reverse 
movement  is  then  executed  with  PR  (fig.  44) . 

At  first  abduction  with  external  rotation  of  the  hip-joint  takes 
place,  and  then  the  reverse.  The  muscles  actively  engaged  are 
the  abductors,  and  some  of  the  external  rotators  of  the  hip-joint. 
The  psoas  and  iliacus  are  not  in  action. 

The  above  exercise  may  be  performed  while  the  patient  lifts 
himself  off  the  couch  somewhat,  resting  on  his  shoulders  and 
heels.  Under  these  circumstances  he  lifts  up  the  whole  pelvic 
floor  and  levator  ani,  an  action  that  exerts  a  powerful  corrective 
effect  on  tendencies  to  prolapse  of  the  rectum  (and  in  female 
patients  of  the  vagina  and  uterus). 


96     ELEMENTS   OF   KELLGREN'S    MANUAL    TREATMENT 


This  exercise  may  also  take  the  form  of  abduction,  PE> 
adduction,  AR,  i.e.,  the  patient  resists  while  the  assistant  (whose 
hands  are  placed  on  the  inner  aspect  of  the  knee-joints)  separates 
his  knees,  and  then  the  reverse.  By  these  means,  blood  is  sent  to 
the  pelvic  organs,  whereas  in  the  former  case  (abduction,  AR, 
adduction,  PR),  blood  is  drawn  away  froixi  them  (cf.  Thure, 
Brandt  1). 


'Massage  bei  Frauenleiden,"  1897,  pp.  99,  100. 


GYMNASTIC   MOVEMENTS  97 


ROTATION    (TURNING). 

By  the  above  term  is  meant  rotation  on  the  axis  which  is 
vertical  in  the  fundamental  standing  position. 

I.— Of  the  Upper  Extremity. 
(1)     At  the   Shoulder-joint. 

Kotations  at  this  joint  can  be  given  with  the  arm  in  heave 
position  and  the  elbow  supported.  The  assistant's  grasp  is  over 
the  wrist-joint,  and  by  means  of  movements  of  the  forearm 
through  the  sector  of  a  circle  (the  centre  of  which  is  the  elbow) 
passive  or  duplicate  movements  of  internal  and  external  rotation 
of  the  humerus  are  accomplished. 

In  internal  rotation,  AR,  external  rotation,  PR,  the  sub 
scapularis,  pectoralis  major,  latissimus  dorsi  and  teres  major  are 
exercised;  in  external  rotation,  AR,  internal  rotation,  PR,  the 
teres  minor  and  infraspinatus  are  in  action. 

(2)     At  the  Wrist-joint. 

Anatomy  text-books  as  a  whole  ignore  the  possibility  of  passive 
rotation  at  this  joint.  That  it  exists,  however,  can  easily  be 
demonstrated.  The  radius  and  ulna  are  fixed  by  the  assistant's 
one  hand ;  the  other,  grasping  the  hand  of  the  patient,  turns  it 
first  in  one  direction  and  then  in  the  other.-^  Such  passive 
rotation  of  the  wrist-joint  can  be  used  in  order  to  free  that  joint 
in  cases  of  adhesions,  stiffness,  &c.  Active  rotation  of  the  wrist 
is,  of  course,  impossible. 

II. — Of  the  Lower  Extremity. 

(1)     At  the    Hip-joint. 

The  patient  is  usually  in  .half  lying  position;  the  toes  are 
moved  through  the  arc  of  a  circle  whose  centre  is  the  heel.     The 

'  Wide  is  not  aware  of  the  fact  that  such  rotation  exists.      See  "  Haudbok  i 
Medicinsk  Gymnastik,"  1896,  p.  358;  "Handbook  of  Medical  Gymnastics,"  1899, 
p.  207  ;  "  Handbok  i  Medicinsk  och  Ortopedisk  Gymnastik,"  1902,  p.  299  ;    "  Hand- 
book of  Medical  and  Orthopaedic  Gymnastics,"  1903,  p.  297. 
7 


98     ELEMENTS    OF   KELLGREX'S   MANUAL    TREATMENT 

knee-joint  being  fully  extended  rotation  at  these  joints  is 
rendered  impossible :  the  whole  movement  is  in  consequence 
transmitted  to  the  hip-joint. 

To  convert  the  exercise  into  a  duplicate  one  resistance  is 
applied  over  the  outer  side  of  the  metatarsus  in  the  case  of 
external  rotation,  AR,  and  over  the  inner  side  in  the  case  of 
internal  rotation,  AR;  or,  better  still,  over  the  outer  and  inner 
surfaces  of  the  knee-joint,  as  in  the  latter  case  traction  can  be 
more  effectually  applied.  One  of  the  assistant's  hands  is  placed 
over  the  knee-joint,  as  mentioned,  while  the  other  guides  the  foot 
in  its  course,  both  performing  traction  away  from  the  hip. 

The  muscles  exercised  are  the  external  and  internal  rotators 
of  the  hip-joint  respectively.  When  the  assistant's  grasp  is  over 
the  foot  alone,  the  eversors  and  inversors  respectively  of  the  tarsal 
joints  are  placed  in  action  in  order  to  maintain  the  position  of 
the  foot.' 

(2)     At  the  Knee-joint. 

Rotation  exercises  are  not  often  applied  to  this  joint,  as  the 
muscles  performing  the  movements  can  be  exercised  in  other 
ways. 

III.— Of  the  Head. 

The  assistant  places  one  hand  on  the  patient's  forehead  and 
the  other  over  his  occiput  (as  in  iig.  4-5).  Applying  traction 
upwards  all  the  time,  the  patient's  head  is  first  turned  to  one 
side,  and  then  to  the  other,  passively  or  with  resistance  as  the 
case  demands.  The  movement  chiefly  affects  the  joint  between 
the  atlas  and  axis.  In  order  to  prevent  over-extension  of  the 
spinal  cord,  the  head  sinks  somewhat  during  the  rotation,  and 
becomes  elongated  again  during  the  reverse  movement. - 

The  muscles  used  to  perform  the  turning  are  those  which 
rotate  the  joint  mentioned,  and  those  which  rotate  the  cervical 
vevtebrfe. 

'  Wide  states  that  in  tliis  exercise  most  of  the  muscles  of  the  leg  are  put  into 
action.  See  "  Handbok  i  Medicinsk  Gymnastik,"  1895,  p.  118;  "Handbook  of 
Medical  Gymnastics,"  1899,  p.  117  ;  "  Handbok  i  Sledicinsk  och  Ortopedisk 
Gymnastik,"  1902,  p.  Ill;  "Handbook  of  Medical  and  Orthopiedic  GjTnnastios," 
1903,  p.  125. 

-  Henke,  "  Handbuch  der  .^natomie  uud  Mekanik  der  Geleuke,"  1863,  p.  9G. 


GYMNASTIC    MOVEMENTS  99 

Rotations  of  the  head  combined  with  flexion  maj'  also  be 
given  (see  flexion,  p.  75). 

IV.-Of  the   Trunk. 
Loin  Lean  Stride  Standing  Alternate  Rotation,  AR. 

The  patient  assumes  the  initial  position  with  neck  firm.  The 
assistant  grasps  the  patient  round  the  elbows,  and  lifting  the 
trunk  upwards  brings  it  passively  into  turn  position.  The 
reverse   movement    is  then  executed  witli  AR   in   front  of  the 


posterior  elbow  and  behind  the  anterior  one  (more  especiall\' 
the  latter),  with  traction  upwards  as  before.  The  whole  process 
is  repeated  on  the  other  side  (fig.  46).  This  movement  may  also 
1)6  performed  from  ride  sitting  or  loin  lean  stride  kneeling 
position . 

In  this  exercise  the  trunk  is  rotated  on  the  vertebral  column 
in  its  dorsal  region.  Suppose  the  patient  to  be  placed  in  right 
turn  position ;  the  muscles  which  bring  him  back  to  the  original 
position  may  be  classed  in  three  great  divisions  : — (1)  External 


loo  ELEMENTS  OF  KELLGREN'S    MANUAL    TREATMENT 

oblique  and  external  intercostals  of  the  right  side.  (2)  Internal 
oblique  and  internal  intercostals  of  the  left  side.  (3)  Eotator 
muscles  of  the  trunk,  i.e.,  multifidus  spinas  and  rotatores  spinae 
of  the  right  side,  semi-spinales  of  the  left  side,  &c. 

In  addition,  the  posterior  scapular,  upper  dorsal  and  cervical 
extensor  muscles  are  powerfully  contracted  in  order  to  maintain 
the  position  of  the  arms  and  head. 


The  effects  are  similar  to  those  induced  by  lateral  flexion  of 
the  trunk  (p.  84).  The  abdominal  contents  are  stimulated  directly 
and  reflexly  (see  p.  78)  ;  the  flow  in  the  portal  vein,  inferior 
vena  cava,  lower  two  azygos  veins  and  the  intercostal  veins 
is  promoted.  The  lymph  flow  in  the  abdomen  and  intercostal 
spaces  is  furthered.  The  spinal  cord  is  probably  stimulated  and 
its  venous  circulation  promoted. 


GYMNASTIC   MOVEMENTS 


PRONATION  AND   SUPINATION. 

These  movements  occur  only  with  regard  to  the  radio-ulnar 
joints. 

The  patient's  forearm  is  flexed  to  about  a  right  angle,  in  order 
to  ehminate  as  much  rotation  as  possible  at  the  shoulder-joint.' 
The  assistant  then  fixes  the  elbow-joint  with  one  hand,  and  with 
the  other  grasps  that  of  the  patient  as  if  he  were  going  to  shake 
hands  ;  the  movements  of  pronation  and  supination,  passive  or 
duplicate,  are  then  executed  {fig.  47  shows  supination,  AR,  pro- 
nation, PE). 


In  ordinary  life,  pronation  and  supination  are  effected  by  first 
grasping  some  object  with  the  hand  and  then  trying  to  turn  it 
one  way  or  the  other.  This  means  that  the  flexors  of  the  fingers 
and  fixators  of  the  wrist-joint  are  called  into  action.  With 
regard  to  supination  it  is  not  usually  mentioned  in  text-books 
that  the  triceps  has  to  work  hard  in  order  to  counteract  the 
tendency  on  the  part  of  the  biceps  to  produce  flexion  of  the 
elbow-joint. 

'  It  cannot  be  entirely  eliminated ;  a  slight  amount  of  rotation  at  this  joint 
always  enters  into  pronation  and  supination.  Sec  Hultkranz,  "Das  EUenbogen- 
gelenk  und  seiner  Mekanik,"  1897,  pp.  81,  82. 


lor     ELEKlilSTS  OF    KELLGREN'S  MANUAL   TREATMENT 

In  the  exercise  of  pronation,  AK,  and  supination,  AE,  with 
the  assistant's  grasp  as  above,  the  pronator  group  and  some  of  the 
flexors  of  the  front  of  the  forearm,  and  the  supinator  group  and 
some  of  the  extensors  on  the  back  of  the  forearm  are  respectively 
in  action.  The  flexors  and  extensors  of  the  forearm  can,  how- 
ever, be  ehminated  b}'  transferring  the  grasp  of  the  assistant 
to  above  the  wrist-joint,  in  which  case  there  is  complete  isolation 
of  the  pronator  and  supinator  group  respectively. 


INVERSION   AND   EVERSION. 

These  movements  onl}'  occur  in  connection  with  the  foot. 
The  patient  is  usually  placed  in  half  lying  position  with  the  lower 
leg  fixed  by  the  assistant's  one  hand  in  the  same  waj'  as  m  foot 
flexion  and  extension  (p.  69),  the  other  hand  being  placed  over 
the  inner  side  of  the  foot  in  inversion,  AK,  and  eversion,  PR,  and 
over  the  outer  side  in  inversion,  PR,  and  eversion,  AR.  In  every 
case  traction  away  from  the  lower  leg  should  be  maintained  while 
the  movements  are  being  executed. 

The  muscles  brought  into  action  are  the  inversors  and  eversors 
of  the  foot  respectively.  The  movement  takes  place  chiefly  at  the 
mediotarsal  joint. 


GYMNASTIC    MOVEMENTS  103 


CIRCUMDUCTION   OR   ROLLING. 

The  range  of  movement  obtained  by  rolling  is  greater  than 
tbat  obtained  from  the  other  classes  of  exercises. 

I.— Circumduction  of  the  Upper  Extremity. 
(1)    Of  the   Shoulder-joint. 

Half  Lying  Double  Arm  Rolling,  PP. 

(Also  called  Arm  "  Flying.") 

The  patient  assumes  the  stretch  half  lying  position,  with  the 
forearms  either  in  the  mid-position  or  pronated.  The  assistant 
grasps  the  patient's  hands  in  his  own  and  performs  a  series  of 
circumductioi:s  of  the  shoulder-joints  by  causing  the  elbows  to 
describe  a  circle,  as  follows  : — 

(1)  He  extends  the  patient's  shoulders  and  flexes  the  elbows 
until  the  upper  arms  lie  against  the  side  of  the  thorax  and  the 
forearms  are  in  extreme  flexion. 

(2)  By  drawing  the  patient's  hands  outwards  and  upwards, 
thus  bringing  about  abduction  of  the  shoulders  and  extension  of 
the  elbows,  he  gets  the  patient's  arms  into  heave  position. 

(3)  Finally,  by  drawing  the  patient's  hands  upwards  and 
inwards,  completing  the  movement  mentioned  in  (2),  he  brings 
the  arms  back  into  the  original  position  (see  fig.  41,  p.  92). 

The  division  into  three  parts  is  merely  for  the  sake  of  clearness 
of  description ;  in  practice  the  rolling  should  be  done  as  evenly 
and  continuously  as  possible,  its  various  phases  merging  into  one 
another  without  a  break. 

The  movement  is  repeated  from  six  to  ten  times,  this  consti- 
tuting the  first  half  of  the  exercise  ("from  within  outwards"). 
It  is  then  executed  a  like  number  of  times  in  the  reverse  direction 
("  from  without  inwards  ").     The  whole  process  is  then  repeated. 

This  exercise  may  be  carried  out  quickly  and  energetically. 
Its  effects  are  then  as  follows : — 


I04  ELEMENTS    OF   KELLGREN'S    MANUAL   TREATMENT 

The  muscles  of  the  whole  limb  and  shoulder  girdle  are 
exercised,  and  become  better  supplied  with  blood ;  the  nerves  ate 
stimulated ;  the  joints  involved  are  rendered  more  supple,  and 
iiuy  stiffness,  deposits  (gouty  or  otherwise),  or  adhesions  that  may 
be  present  will  tend  to  be  removed.  The  circulation  in  the 
arteries  and  veins  will  be  furthered,  the  latter  being  partly 
affected  by  Braune's  suction  and  pumping  apparatus  (described 
on  p.  48).  An  additional  effect  is  produced  on  the  venous  flow 
through  the  inertia  of  the  blood  and  the  presence  of  valves  in  the 
veins.  While  the  arm  is  passing  from  stretch  position  downwards 
towards  the  body,  the  venous  blood  of  the  forearm,  which  tends 
to  accumulate  in  the  hand  in  consequence  of  its  inertia,  is 
prevented  from  doing  so  because  of  the  valves  in  the  veins,  and 
thus  moves  in  unison  with  the  forearm.  When  the  arm  is  drawn 
up  again  the  blood  in  the  forearm  continues  to  move  towards  the 
heart  by  its  own  inertia.  A  similar  mechanism  comes  into  play 
in  leg  rolling  (see  p.  107).  The  lymphatic  circulation  in  the  arm 
is  promoted,  and  the  onward  passage  of  the  contents  of  the 
thoracic  duct  is  hastened  (p.  49).  The  exercise  also  acts  bene- 
ficially on  the  respiratory  apparatus  from  the  alternate  lifting  up 
and  down  of  the  chest. 

This  exercise  ma}'  be  carried  out  slowly,  e.g.,  in  the  case 
of  heart  disease  patients,  in  whom  it  is  desired  to  produce  the 
reaction  slowly,  or  if  it  is  intended  to  convert  the  exercise  into  a 
purely  respiratory  movement.  In  the  latter  case  the  patient 
inspires  deeply  as  the  arms  are  brought  into  stretch  position,  and 
makes  a  deep  expiration  when  the  process  is  reversed.  Under 
such  circumstances  the  stimulatory  effects  on  the  arms  are  not  so 
great  as  when  the  movement  is  executed  rapidly ;  the  exercise, 
becoming  identical  with  a  passive  chest  expansion,  acts  chiefly  on 
the  lungs. 

Sitting  Arm  Circling,  PP. 

In  the  movement  just  described  it  is  impossible  to  apply  any 
traction  excepting  at  the  very  moment  that  the  arms  are 
brought  into  stretch  position.  If,  therefore,  an  inflammatory 
condition  of  the  shoulder-joint  or  a  freshly-reduced  dislocation 
be  under  treatment,  it  may  be  necessary  to  give  the  rolhng  in 
such  a  position  and  in  such  a  way  that  traction  of  the  arm  away 
from  the  shoulder  can  be  exercised.     This  is  effected  by  placing 


GYMNASTIC   MOVEMENTS 


105 


the  patient  in  the  sitting  position  ;  the  shoulder  of  the  arm  that 
is  to  be  rolled  is  fixed  by  the  assistant's  one  hand ;  if  necessary, 
his  fingers  are  placed  round  the  head  of  the  humerus  to  prevent 
re-dislocation.  His  other  baud  is  used  to  grasp  the  forearm  just 
below  the  elbow-joint,  which  he  semi-flexes,  at  the  same  time 
abducting  the  humerus  to  about  a  right  angle.  Then,  perform- 
ing traction  away  from  the  shoulder,  the  assistant  moves  the 
elbow  in  a  gradually  increasing  circle  first  in  one  direction  and 
then  in  the  other  (fig.  48). 


This  movement  is  executed  slowly  and  through  a  compara- 
tively small  radius  ;  its  main  efi'ects,  therefore,  are  the  furthering 
of  the  venous  and  lymphatic  flow  and  the  prevention  of  adhesions 
and  inflammation  in  the  neighbourhood  of  the  shoulder-joint. 

Should  a  case  arise  demanding  even  greater  traction,  arm 
circling  may  be  carried  out  with  the  arm  in  yard  position,  i.e., 
the  elbow  is  fully  extended.  The  patient  is  then  conveniently 
in  half  lying  position.  The  assistant  uses  one  hand  to  fix  the 
patient's  shoulder,  and  the  other  grasps  the  patient's  hand 
(fig.  55).  Applying  traction  of  the  latter  away  from  the  trunk, 
the  assistant  moves  it  in  a  gradually  increasing  circle  first  in 
one  direction  and  then  in  the  other. 


io6  ELEMENTS   OF    KELLGREN'S    MANUAL    TREATMENT 

Ann  circlin<T  as  just  described  may  also  take  place,  in  order  to 
free  the  shoulder-joint,  with  the  arm  in  stretch  position,  or  in 
any  phase  intermediate  between  that  and  yard  position. 

Walk  Standing  Double  Arm  Circling,  PA. 

(See  p.  130.) 

(2)    Of  the    Wrist-joint. 

Sitting  Hand  Rolling,  PP. 

The  patient's  forearm  is  fixed  horizontally  by  the  assistant 
with  one  hand,  his  other  hand  being  used  to  grasp  the  patient's 


fingers.  Keeping  up  traction  away  from  the  forearm,  the  assis- 
tant performs  circumduction  of  the  hand  at  the  wrist-joint  six 
to  ten  times,  first  in  one  direction  and  then  in  the  other  (fig.  49). 
The  whole  process  is  then  repeated. 

This  movement  is  a  combination  of  passive  palmar,  dorsal, 
ulnar,  and  radial  flexion,  together  with  rotation,^  at  the  wrist- 
joint.  Circulatory,  muscular,  nervous,  and  other  effects,  as  regards 
the  hand  and  forearm,  are  as  already  described. 

(3)  Of  the  Thumb  and   Fingers. 

(a)  The  thumb  is  rolled  together  with  its  metacarpal  bone,  as 
there  is  only  a  small  amount  of  circumduction  possible  at  its 

-  See  p.  97. 


GYMNASTIC    MOVEMENTS  107 

metacarpo-phalangeal  joint.  To  execute  the  movement  the  wrist- 
joint  and  other  metacarpals  must  be  fixed ;  the  assistant  grasps 
the  terminal  phalanx  of  the  thumb,  and  while  keeping  up  traction 
away  from  the  wrist  performs  the  rolling  first  in  one  direction 
and  then  in  the  other. 

The  movement  takes  place  in  the  joint  between  the  first 
metacarpal  and  the  trapezium.  .  The  muscular,  circulator)', 
nervous,  &c.,  effects  are  as  previously  described. 

(b)  The  fingers  may  be  rolled  in  a  similar  manner,  with  their 
corresponding  metacarpal  bone  fixed  (fig.  -50).    The  circumductory 


movement  takes  place  in  the  metacarpo-phalangeal  joint.     The 
effects  are  on  the  lines  indicated. 

When  it  is  desired  to  apply  greater  traction  than  accompanies 
the  above  methods,  this  can  be  effected  by  transferring  the  grasp 
of  the  assistant's  one  hand  from  the  terminal  to  the  first 
phalanx. 

II.— Circumduction  of  the   Lower  Extremity. 
(1)    Of  the    Hip  Joint. 

Half  Lying  Leg  Rolling,  PP. 

(This  exercise  can  also  be  carried  out  with  both  legs  at  once.) 

The  patient  assumes  the  half  lying  position  with  neck  firm. 
The  assistant,  grasping  the  foot  and  knee  as  in  the  case  of  half 


loS  ELEMENTS    OF   KELLGREX'S   MANUAL    TREATMENT 

lying  leg  flexion,  PP,  extension,  AR  (see  p.  64),  performs  a 
series  of  circumductions  of  the  bip-joint  by  causing  the  knee 
to  describe  a  circle.     This  is  effected  as   follows  : — 

(1)  He  performs  flexion  of  the  knee  and  thigh  to  nearly  the 
maximum  extent. 

(2)  Then  he  rotates  the  thigh  outwards  and  abducts  it. 

(3)  Fmally  he  draws  the  foot  directly  away  from  the  trunk 
and  brings  the  limb  back  to  its  original  position  by  means  of 
internal  rotation,  adduction,  and  extension  of  the  thigh,  and 
extension  of  the  knee. 

The  heel  should  throughout  be  kept  in  the  middle  line. 

The  division  into  three  parts  (just  as  in  the  case  of  arm 
rolling)  is  merely  for  the  sake  of  clearness  of  description  ;  in 
practice  the  rolling  should  take  place  as  evenly  and  continuously 
as  possible,  the  various  phases  merging  into  one  another  without 
a  break. 

The  movement  is  executed  six  to  ten  times  according  to  the 
above  description  (from  within  outwards),  and  then  the  same 
number  of  times  in  the  reverse  direction  (from  without  inwards). 
The  whole  process  is  then  repeated. 

The  effects  of  this  exercise  as  regards  the  muscles,  nerves, 
lymphatic  and  blood  circulation,  joints,  &c.,  are  similar  to  those 
described  in  connection  with  passive  movements  (pp.  38,  39). 
Mention  has  also  been  made  of  the  special  n:echanisms  that  aid 
the  flow  in  the  popliteal  and  femoral  veins  (pp.  59,  64,  6.5),  and 
of  the  mechanism  in  the  lower  leg,  which  consists  of  a  combi- 
nation of  inertia  of  the  blood  and  valves  in  the  veins  (p.  104). 

In  the  case  of  moderate  stiffness  or  inflammation  at  the  hip- 
joint  the  movement  should  be  given  more  slowly,  and  with 
traction  away  from  the  pelvis ;  the  latter  is  applied  by  the 
assistant  placing  one  hand  in  the  bend  of  the  knee,  and  drawing 
the  thigh  away  from  the  trunk  while  the  rolling  is  performed. 
When  this  exercise  is  given  slowly  the  stimulatory  effects  are  not 
so  marked  as  when  it  is  given  rapidly. 

In  the  case  of  very  great  pain  or  acute  inflammatory  state  of 
the  hip-joint  (where  even  the  rolling  just  mentioned  cannot  be 
carried  out),  the  movement  can  be  performed  as  follows: — The 
patient's  knee  being  fully  extended,  the  assistant  grasps  the  foot 
and  draws  it  directly  away  from  the  pelvis ;  by  moving  it  in  a 
gradually  increasing  circle  first  in  one  direction  and  then  in  the 


GYMNASTIC    MOVEMENTS  109 

reverse,  he  causes  a  circumductory  movement  to  take  place  at  the 
hip-joint.  The  effects  are  similar  to  those  that  take  place  in 
sitting  arm  circling,  PP. 

(2)    Of  the    Foot. 
Half  Lying  Foot  Rolling,   PP. 

The  position  of  the  patient  and  the  grasp  of  the  assistant  are 
the  same  as  for  half  lying  foot  flexion  and  extension  (p.  69). 
The  assistant  performs  circumduction  of  the  foot  first  six  to  ten 
times  in  one  direction,  and  then  the  same  number  of  times  in  the 
reverse  direction  ;  the  whole  process  is  then  repeated. 

The  rolling  takes  place  in  the  ankle  and  tarsal  joints  ;  no 
movement  should  take  place  in  the  hip-joint,  as  due  fixation  of 
the  lower  leg  prevents  any  transmission  of  the  rotation  up  the  leg. 
The  muscular,  circulatory,  nervous,  &c.,  effects  are  the  same  as 
already  indicated  with  respect  to  the  foot  and  lower  leg. 

Half  Lying  Double  Foot  Rolling,  PP. 

(The  same  movement  as  the  last,  but  involving  both  feet  at  once). 

The  position  of  the  patient  and  the  assistant's  grasp  are  the 
same  as  for  half  lying  double  foot  flexion  and  extension  (p.  70). 
The  assistant  performs  circumduction  of  both  feet  simul- 
taneously, first,  six  to  ten  times  in  one  direction,  and  then  the 
same  number  of  times  in  the  reverse  direction.  The  whole 
process  is  then  repeated. 

The  effects  are  similar  to  those  obtained  from  the  last  exer- 
cise, although  not  so  marked.  This  is  because,  the  lower  legs 
not  being  so  completely  fixed,  the  movement  cannot  be  accom- 
plished so  energetically  and  through  so  great  a  range  ;  otherwise 
the  hip-joints  rotate  in  unison  with  the  rolling  of  the  foot,  a 
result  distinctly  undesirable,  and  one  which  must  be  avoided  as 
much  as  possible.' 

'  Compare  Wide,  "  Handbok  i  Medicinsk  Gymnastik,"  1S95,  p.  132  ;  "  Handbook 
of  Medical  Gymnastics,"  1899,  p.  131;  "Handbok  i  Medicinsk  och  Ortopedisk 
Gymnastik,"  1902,  p.  121;  "Handbook  of  Medical  and  Orthopfedic  Gymnastics," 
1903,  p.  139. 


no    ELEMENTS  OF  KELLGREN'S   MANUAL    TREATMENT 

(3)  Of  the  Toes. 

The  corresponding  metatarsal  l)one  being  fixed,  the  toe  is 
rolled  in  the  same  manner  as  the  fingers  (see  p.  107).  The  effects 
are  as  already  described. 

III.— Circumduction  of  the  Head. 
Sitting  Head  Rolling,  PP. 

The  assistant  with  one  liand  over  the  patient's  occiput  and 
the  other  over  the  forehead  (as  in  fig.  4.5,  p.  99),  slowly  rolls  the 
patient's  head  first  in  one  direction  and  then  in  the  reverse 
direction,  continually  keeping  up  traction  away  from  the  trunk. 
Unlike  the  other  rollings,  this  kind  is  never  given  energetically. 

This  movement  is  a  combined  one  of  flexion  and  extension  of 
the  occipito-atlantal  joint,  rotation  of  the  atlanto-axial  joint,  and 
flexion  forwards,  sideways,  and  backwards  of  the  cervical  vertebra. 

The  effects  on  the  muscles  and  nerves  of  the  neck  and  vessels 
of  both  neck  and  brain  are  as  already  described  (p.  73).  This 
movement  is  depletive  for  the  brain. 

IV.— Circumduction  of  the  Trunk. 

Ride  Sitting  Screw  Turning,  PP. 

This  movement  is  a  combination  of  flexion  forwards  and 
extension  backwards,  lateral  flexion  and  rotation  of  the  trunk, 
and  is  performed  as  follows  :  — 

The  patient  assumes  the  ride  sitting  position  with  neck  firm 
and  the  feet  fixed.  The  assistant's  grasp  is  at  first  the  same  as 
for  alternate  rotation  (see  p.  99),  and  he  begins  by  rotating  the 
patient's  trunk  to  one  side  (say  to  the  right)  until  the  patient 
reaches  right  turn  position  (fig.  .51).  Thereupon  he  leaves  hold 
of  the  patient's  right  elbow,  and  places  his  right  forearm  across 
the  right  half  of  the  patient's  back,  and  his  right  hand  in  the 
right  axilla.  Then  he  also  leaves  hold  of  the  patient's  left  elbow 
and  places  bis  hand  on  the  patient's  left  thigh  to  steady  him. 
After  this  he  swings  the  patient's  trunk  round  so  that  the 
patient's  head  describes  a  circle  the  direction  of  which  is  positive 
as  seen  from  above,  and  the  centre  of  which  is  the  position  his 
head  would  occupy  if  placed  in  ride  fall  sitting  position.     While 


G YMNASTIC  iMO VEMENTS 


doing  this,  the  assistant  simultaneously  perfonus  rotation'of  the 
trunk  on  itself  also  in  a  positive  direction  as  seen  from  ahove, 
so  that  at  the  completion  of  the  circle  it  is  in  left  turn  position 


Fig.  52. 

(fig.  5i).  The  assistant  then  rotates  the  patient  back  again  to 
the  original  position.  The  screw  turning  is  given  three  times 
in  the  same,  and  then  three  times  in  the  reverse  direction. 


112    ELEMENTS  OF  KELLGREN'S  MANUAL  TREATMENT 

The  assistant's  grasp  varies  somewhat  during  the  different 
stages  of  the  movement,  and  is  best  gathered  from  the  ilhistra- 
tions  (figs.  51  to  54). 


This   movement  is  a  complex  one,  and  its  chief  component 
parts  are  as  follow  : — 


GTMNASTIC  MOVEMENTS  113 

(«)  Extension  of  the  trunk  at  the  hip-joints  through  a  range 
of  about  90°,  and  the  reverse  movement. 

(b)  Complete  rotation  of  the  trunk  from  right  turn  to  left  turn 
position,  and  vice  versa. 

(c)  Some  lateral  flexion  of  the  trunk  and  the  reverse  move- 
ment. 

The  sum  of  these  operations  is  circumduction  of  the  trunk. 
Both  the  abdominal  and  thoracic  contents  are  stimulated.  The 
effect  is,  in  fact,  a  combination  of  the  effects  obtained  from  passive 
falling  backwards  and  the  reverse,  passive  alternate  rotation  and 
ringin". 


114    ELEMENTS  OF  KELLGREX'S  MAXCAL   TREATMENT 


TRACTION. 

During  all  duplicate  movements,  wherever  possible,  the 
assistant  keeps  up  traction  of  the  part  exercised  by  dravi'ing 
its  distal  free  end  away  from  its  proximal  fixed  end.  This 
traction  has  alreadj'  been  described  and  repeatedly  insisted  on, 
and  the  physiological  effects  of  the  process  have  also  been  con- 
sidered (pp.  27,  28). 

Under  the  heading  of  traction  will  be  described  some  passive 
exercises  used  especially  in  order  to  stretch  certain  parts.  During 
all  of  them,  unless  otherwise  stated,  the  patient  should  offer  no 
resistance  to  the  stretching,  but  on  the  contrary  should  try  to 
remain  as  passive  as  possible. 

Arm  Traction  Sideways,  PP. 

The  assistant,  fixing  the  patient's  shoulder,  grasps  the 
patient's   hand   and   brings    his    arm    into    yard    position.      He 


then  draws  the  patient's  hand  directly  away  from  the  trunk 
and  maintains  this  traction  for  a  few  .seconds  (fig.  55).  The 
result  is  stimulation  of  the  whole  extremity.  The  cords  of  the 
brachial  plexus  as  they  lie  in  the  axilla  can  be  felt  to  become 
very  tense  during  the  application  of  the  traction. 


GYM.WASTIC    MOVEMENTS  115 

This  luovemeiit  luay  also  be  administered  as  partly  duplicate, 
in  which  case  the  assistant  first  performs  traction  of  the  patient's 
arm  as  above,  and  then  the  patient,  keepin/j;  his  trunk  still,  tries 
to  draw  the  arm  towards  himself  with  AK.  At  first  stimulation 
of  the  arm  results  from  the  traction,  after  which  almost  all 
the  muscles  that  pass  from  the  clavicle  and  scapula  to  the 
humerus  are  activelj'  contracted.  This  movement  is  very  suitably 
made  use  of  just  after  reduction  of  dislocations  of  the  humerus. 


Stretch  Half  Lying  Double  Arm  Traction,  PP. 

The  patient  assumes  the  stretch  half  lying  position.  The 
assistant,  grasping  the  patient's  hands  in  the  same  manner  as  for 
double  arm  bending  and  stretching,  AR,  and  double  arm  rolling, 
PP,  draws  them  away  from  the  shoulders  in  the  plane  in  which 
they  are  lying,  and  maintains  this  traction  for  a  few  seconds. 

The  effect  is  stimulation  of  the  whole  of  the  arm,  and,  in  a 
minor  degree,  stimulation  of  the  trunk. 

The  above  manipulation  is  not  carried  out  separately,  but  is 
both  a  convenient  introduction  and  sequel  to  the  exercises  just 
mentioned. 


Side  Lying  Leg  Traction,  PP. 

The  assistant  grasps  the  foot  of  that  leg  of  the  patient  which 
lies  uppermost,  and  drawing  it  directly  away  from  the  pelvis, 
maintains  this  traction  for  a  few  seconds,  thereby  stimulating 
the  entire  limb,  and  to  a  less  extent  the  lateral  half  of  the  trunk 
of  the  same  side. 


Stretch  Half  Lying  Double  Hand  and  Foot  Traction,  PP. 

The  patient  assumes  the  stretch  half  lying  position,  with  the 
palms  of  the  hands  looking  directly  forwards.  Two  assistants, 
one  grasping  the  patient's  hands,  and  the  other  his  feet,  stretch 
the  patient  by  simultaneously  pulling  in  opposite  directions  for 
a  few  seconds  (fig.  56).  The  effect  is  stimulation  of  the  trunk 
and  limbs  as  a  whole. 


Il6    ELEMENTS  OF  KELLGREX'S  MANUAL    TREATMENT 


When  the  patient  is  a  strong  subject,  and  the  amount  of 
traction  applicable  proves  sufficient  to  lift  him  off  the  bench,  the 
initial  position  can  be  made  the  stretch  lying  one  instead  of  that 
specified  above. 

Stretch  Side  Lying  Hand  and  Foot  Traction,  PP. 

Tvi'o  assistants,  one  grasping  the  patient's  uppermost  hand, 
and  the  other  his  uppermost  foot,  proceed  as  before  (fig.  57). 


The  effect  is  stimulation  of  those  limbs  and  that  lateral  half 
of  the  trunk  which  lie  uppermost. 

All  the  foregoing  tractions  may  be  administered  with  simul- 
taneous vibration  of  the  part  (see  p.  189).  (See  also  vibrations 
and  shakings  of  joints,  p.  194.) 


GYMNASTIC  MOVEMENTS 


(ARM-)   CARRYING. 

This  is  a  term  used  to  denote  certain  movements  of  the  arm  at 
the  shoulder-joint.     Two  examples  will  be  given. 

High  Sitting  Double  Arm  Carrying  Outwards,  AR,  Inwards,  PR. 

The  patient  assumes  the  high  sitting  position  with  his  back 
supported.  He  first  brings  his  arms  into  reach  position,  and  then, 
with  AE  over  the  dorsal  aspect  of  the  metacarpals,  carries  his 


arms  horizontally  outwards  and  backwards  as  far  as  possible, 
keeping  the  shoulders  drawn  well  down  and  back.  The  reverse 
movement  is  then  executed  with  PR  (fig.  .58). 

This  movement  is  given  chiefly  to  expand  the  chest,  in  conse- 
•luence  of  the  powerful  action  of  the  muscles  that  pass  from  the 


ii8    ELEMENTS  OF  KELLGREN'S   MANUAL   TREATMENT 

trunk  to  the  scapula  and  from  the  scapuhi  to  the  humerus  pos- 
teriorly ;  the  posterior  muscles  of  the  forearm  are  also  exercised. 
The  movement  at  the  shoulder-joint  is  not  an  ordinary  simple  one 
of  flexion,  or  abduction,  or  rotation,  &c.,  nor  is  it  circumduction. 
It  is  a  kind  of  eighth  movement  of  that  joint,  and  consists  ni 
the  gliding  of  the  head  of  the  horizontally-held  humerus  on  the 
glenoid  fossa,  the  line  of  contact  being  approximately  represented 
by  about  the  anterior  two-thirds  of  a  line  drawn  from  the  upper 
end  of  the  bicipital  groove  across  the  head  of  the  humerus  in  the 
long  axis  of  that  bone. 

During  the  arm-carrying  outwards  the  scapula  moves  inwards 
a  little,  the  reverse  taking  place  during  the  reverse  movement 

Sitting  Elbow  Carrying  Backwards,  AR,  Forwards,  PR. 

(Also  called  elbow  pressing  backwards,  &c.) 

This  exercise  is  accomplished  with  one  arm  at  a  time.  The 
patient  places  his  upper  arm  in  a  position  about  midway  between 
yard  and  reach  positions,  the  rest  of  the  arm  being  as  in  swim 
position.  The  assistant  places  one  hand  on  the  patient's  shoulder 
to  steady  it,  and  the  other  over  the  lower  end  of  the  upper  arm 
posteriori}'.  Then  the  patient,  continually  keeping  the  various 
parts  of  his  arm  horizontal,  causes  his  elbow  to  pass  backwards 
as  far  as  he  can  with  AR.  The  reverse  movement  is  then 
executed  with  Pll. 

The  muscles  involved  are  chiefly  the  posterior  third  of  the 
deltoid  and  the  upper  part  of  the  triceps. 

The  movement  at  the  shoulder-joint  that  takes  place  in  the 
above  two  exercises  is  also  found  in  reach  grasp  stoop  fall  standing 
double  elbow  flexion  and  extension,  PA  (p.  52). 


G YMNA STIC  ^[OV^^!E^^TS 


DRAWING. 

The  explanation  of  this  term  is  best  obtained  from  the  descrip- 
tion of  the  various  movements  it  comprises.  There  are  three 
varieties  :  (1)  drawing  forwards;  (2)  drawing  sideways;  (3)  drawing 
backwards.  The  first  two  of  these  are  closely  allied  to  on.e 
another,  whereas  the  third  is  of  quite  a  different  nature. 

I. — Drawing   Forwards. 
Stretch  Grasp  Standing  Drawing  Forwards,  PP. 

Tlie  patient  assumes  the  stretch  grasp  standing  position. 
The  assistant  stands  in  front  of  him  and  places  his  hands  over 
the  upper  part  of  the  patient's  scapulae,  so  that  his  palms  lie  in 
contact  with  them,  and  look  directly  forwards,  the  fingers  at  the 
same  time  pointing  directly  upwards.  Drawing  towards  himself 
the  assistant  causes  his  hands  to  glide  down  the  patient's  back, 
keeping  close  to  the  spine  in  so  doing,  until  the  lumbar  region 
is  reached,  when  he  brings  his  hands  round  the  sides  of  the 
abdomen,  the  patient  then  either  passively  gliding  back  through 
them  to  the  original  position  by  means  of  his  own  weight  and 
the  elasticity  of  his  body,  or  drawing  himself  back  while  the 
assistant  resists.  The  patient's  feet  should  touch  the  ground  the 
whole  time  (fig.  -59). 

If,  instead  of  beginning  high  up  over  the  scapulae,  the 
assistant's  hands  were  to  start  in  the  lumbar  region,  the  exercise 
would  be  deprived  of  a  great  deal  of  its  efhcacy. 

The  effects  are  stretching  of  all  the  muscles,  ligaments,  nerves, 
vessels,  &c.,  of  the  anterior  part  of  the  arms,  trunk,  and  thighs, 
with  a  certain  amount  of  stretching  of  the  posterior  part  of  the 
arms  and  trunk  (including  the  spinal  column),  with  subsequent 
relaxation  of  all  these  structures.  The  anterior  abdominal 
muscles  are  first  passively  elongated  and  then  passively  shortened 
or  concentrically  contracted,  according  to  circumstances.  The 
abdominal  viscera  as  a  whole  are  stimulated  in  consequence  of  the 


I20    ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

alternate  stretching  and  relaxation  and  alternate  application  and 
removal  of  pressure.  This  movement  is  therefore  conveniently 
given  both  as  an  introduction  and  a  sequel  to  manipulations  on 
many   abdominal   organs.      It   is,  moreover,   a   chest   expansion 


exercise,  in  consequence  of  the  lifting  up  of  the  arms  to  stretch 
position  ;  the  expansion  is  increased  when  the  body  is  drawn 
forwards. 

Heave  Grasp  Standing  Drawing  Forwards,  PP. 

The  patient  assumes  the  heave  grasp  standing  position,  and 
the  assistant  proceeds  as  in  the  case  of  the  last  exercise,  taking 
care,  however,  that  his  manipulation  is  directed  to  expanding  the 
chest,  and  not  to  pulling  the  abdomen  forwards. 

This  movement  is  a  chest  expanding  one  (see  p.  129). 


GYMNASTIC  MOVEMENTS  121 

II. — Drawing   Sideways. 
Side  Span  Standing  Drawing  Sideways,  PP. 

The  patient  assumes  the  side  span  standing  position.  The 
assistant,  who  stands  as  for  drawing  forwards,  places  his  hands 
on  the  patient  over  the  infra-axillary  region  nearest  the  appa- 
ratus, as  in  fig.  60,  keeping  his  palms  looking  as  much  as 
possible  directly  forwards.     Applying  pressure  towards  himself, 


the  assistant  causes  his  hands  to  glide  down  along  the  patient's 
body  until  they  reach  the  crest  of  the  ilium,  thus  drawing  the 
patient  at  about  his  middle  away  from  the  ladder.  He  then  lets 
his  hands  slip  round  the  patient's  body,  which  passes  back  to  the 
original  position  either  passively  or  by  his  own  efforts,  just  as 
described  under  drawing  forwards.  When  this  exercise  is  properly 
administered  the  stretching  is  felt  in  the  lateral  aspect  of  both 
thorax  and  abdomen. 


122    ELEMEXrs  OF  KELLGIiEX'S  MAXUAL    TREATMENT 

Stretching  takes  place  of  all  the  muscles,  ligaments,  nerves, 
vessels,  &c'.,  of  the  lateral  half  of  the  hody  remote  from  the  ladder, 
vv'ith  subsequent  relaxation.  The  lateral  flexors  of  the  other  side 
of  the  trunk  are  first  shortened,  and  the  spinal  column  slightly 
flexed  so  that  its  concavity  lies  tow^ards  the  ladder.  Then  the 
spinal  column  returns  to  its  original  position  either  by  the 
elasticity  or  concentric  contraction  of  the  flexors  of  the  lateral 
half  of  the  body  which  has  been  elongated. 

This  movement  forms  both  a  convenient  introduction  and 
sequel  to  many  manipulations  on  abdominal  organs,  just  as 
stretch  grasp  standing  drawing  forwards,  PP. 


III. — Drawing   Backwards. 

Loin  Lean  Stride  Standing  Drawing  Backwards,  PR, 
Forwards,  AR, 

The  patient  assumes  the  loin  lean  stride  standing  position 
with  neck  firm,  and  draws  his  abdomen  well  inwards  and  up- 
wards, specially  in  cases  of  disease  of  the  pelvic  organs,  or  hernia 
through  the  anterior  abdominal  wall  (see  p.  82).  The  assistant 
grasps  the  patient's  elbows  and  applies  traction  upwards ;  he 
then  causes  extension  of  the  trunk  backwards  on  itself,  the 
patient  meanwhile  resisting  somewhat  and  keeping  his  pelvis 
immovable  and  his  knees  quite  straight.  The  amount  of  exten- 
sion of  the  trunk  on  itself  that  can  be  effected  varies  in  different 
cases.  It  should,  however,  never  be  carried  out  to  its  fullest 
extent,  otherwise  the  inguinal  canal  would  be  drawn  open  and  a 
hernia  easily  result.  The  reverse  is  then  executed  with  AR 
(fig.  61). 

This  movement  may  also  be  performed  from  the  loin  lean 
stride  kneeling  position. 

The  anterior  abdominal  muscles,  together  with  the  psoas,  are 
at  first  in  excentric  and  then  in  concentric  contraction. 

The  effect  on  the  flow  in  the  veins'  and  lymphatics  of  the 
thorax  and  abdomen  and  on  the  spinal  cord  and  size  of  the  spinal 
canal  °  are  very  similar  to  those  which  result  from  lateral  flexion, 

'  Cf.  Neumann,  "  Lehrbuch   der   Leibesiibungeu,"   1856,   part  ii.,  p.   136,  &c. 
Oeorgii,  "  Kinetic  Jottings,"  1880,  pp.  112,  &c. 
-  Reid  and  Sherrington,  quoted  p.  84, 


GYMNASTIC  MOVEMENTS  123 

alternate   rotation,    and    ringing   of   the   trunk.  An   interesting 

experiment  in  connection  with  the  effect  of  this  exercise  on  the 
arteries  is  quoted  by  Georgii.' 


Tlie  actual  luoveuient  that  takes  place  is  extension  backwards 
(and  then  the  reverse)  of  the  trunk  on  itself,  the  hip-joints  not 
participating  (see  classification  of  trunk  flexions,  p.  76). 


'  "  Kinetic  Jottings,"  1880,  p.  113. 


124    ElMMJCX/S  Ol'    KIA-LGRES'S  MANUAL    J  KLATMENT 


EXPANSION. 

This  term  is  onl^-  applied  to  certain  chest  movements  given 
for  the  purpose  of  developing  the  respiratory  apparatus. 

Every  active  movement,  whether  duplicate  or  not,  involves 
chest  expansion,  as  the  cardinal  rule  must  always  be  strictly 
attended  to,  "  Keep  the  head  up,  the  chin  in,  and  the  shoulders 
down  and  back  as  much  as  possible  during  the  execution  of  each 
movement."  Allan  Broman,^  writing  on  the  subject  of  Ling's 
pedagogical  gymnastics,  says,  "  Every  gymnastic  exercise  should 
be  done  under  conditions  of  full  and  free  breathing.  An  exercise 
which  does  not  permit  this  is  bad  educationally,  and  should  be 
eradicated.  In  fact,  every  gymnastic  exercise  rightly  executed  is  a 
resjdratory  movement." 

This  postulate  of  pedagogical  gymnastics  is  of  equal  im- 
portance in  medical  gymnastics.  It  is  necessary  to  pay  so 
much  attention  to  the  respiratory  function,  because  on  it  are 
dependent,  to  a  greater  or  less  extent,  many  vital  phenomena. 

The  effects  of  respiration  are  briefly  as  follows  : — • 

(1)   On  the  Circulation  of  the  Blood. 

Respiration  assists  the  onward  progress  of  the  blood  in  the 
pulmonary  veins  as  follows  : — During  inspiration  is  established  a 
negative  pressure  in  the  thorax  (which  may  amount  to  as  much 
as  70  mm.  of  mercury).  This  causes  an  increase  in  the  size  of 
the  intra-pulmonar}^  veins,  and  a  diminished  resistance  to  the 
flow  in  them  ;  a  suction  power  arises  and  they  fill  up  with  blood 
drawn  peripherally.  During  expiration  is  established  a  positive 
pressure  in  the  thorax  (which  may  amount  to  as  much  as 
100  mm.  of  mercury)  and  the  capacity  of  the  veins  is  dimin- 
ished. The  contents  of  these  veins  are  therefore  driven  in  a 
centripetal  direction  into  the  left  auricle.  Thus  the  diastolic 
filling  of  the  left  auricle  is  aided  by  the  respiratory  peripheral 
force  and  suction  pump. 

'  "  School  Gymnastics,"  1902,  p.  27. 


GYMNASTIC  MOVEMENTS  125 

liespiration  also  assists  the  onward  progress  of  the  blood 
in  the  systemic  veins  as  follows : — The  alternate  increase  and 
decrease  in  the  intrathoracic  pressure,  as  just  mentioned,  will 
alternately  pump  and  force  the  blood  out  of  the  intrathoracic 
portion  of  the  superior  and  inferior  vense  cavae  and  thus  aid  the 
work  of  the  right  auricle.  The  flow  in  the  intra-abdominal  por- 
tion of  the  inferior  vena  cava  and  its  tributaries  will  be  promoted 
by  the  descent  of  the  diaphragm  and  the  expiratory  contraction 
of  the  abdominal  muscles. 

According  to  Loven^  the  attachment  of  the  walls  of  the 
inferior  vena  cava  to  the  foramen  quadrilaterum  is  such  that 
with  the  descent  of  the  diaphragm  they  are  drawn  apart,  an 
increase  in  the  capacity  of  the  vein  ensuing.  "With  sedentary 
persons  who  suffer  from  a  congestive  state  of  the  large  venous 
trunks  an  occasional  deep  inspiration  is  a  powerful  means  of 
facilitating  the  circulation."  (Loven^).  In  the  case  of  persons 
with  very  thin  skins,  the  long  saphenous  veins  can  be  seen  to 
alternately  fill  and  empty  with  the  movements  of  respiration 
(Sch  weigger-Seidel  ^) . 

That  the  movements  of  the  diaphragm  further  the  blood 
supply  in  the  liver  and  spleen,  and  also  the  onward  progress 
of  the  contents  of  the  stomach  and  intestines,  has  been  shown 
by  Hasse.* 

(2)   On   the   Flow   of  the   Lymph. 

Every  inspiration  induces  increased  intra-abdominal  and 
decreased  intrathoracic  pressure ;  thus  the  contents  of  the 
abdominal  part  of  the  thoracic  duct  are  emptied  into  the 
thoracic  part.  During  expiration  these  changes  of  pressure 
are  reversed  ;  but  the  contents  of  the  duct,  in  consequence 
of  the  valves,  cannot  pass  backwards,  and  instead  are  driven 
onwards    into    the    subclavian    vein.        There    is    an    additional 


'  "Om  Blodet,"  1876,  p.  47. 

-  Op.  cit.,  p.  4G  (translated).  Sec  also  Oliver,  '■  The  Blood  aud  Blood  Pressure," 
1901,  p.  180. 

'  Quoted  by  Braune,  "  Die  Oberscheukelveue  des  Jlenscben  in  Anatomischer  uud 
Kliuischer  Beziehung,"  1873,  p.  3. 

<  "  Ueber  die  Bewegungen  des  Zwerchfells  und  iiber  den  Einfluss  derselben  auf  die 
Unterleibsorgane,"  in  Archiv  fiir  Anat.  und  Phys.,  Aiiat.  Abtheilung,  1886,  pp.  185- 
■210  ;  and  "  Ueber  die  Bauchatbmung,"  ibid.,  1903,  pt.  i.,  pp.  43-26. 


126    ELEMENTS  OF  KELLGKEX'S  ^L^NUAL   TREATMENT 

indirect  effect  of  respiration  on  the  lymph  flow ;  the  negative 
pressure  induced  in  the  intrathoracic  venous  trunks  causes  a 
suction  of  the  contents  of  the  thoracic  duct  into  the  subclavian 
vein,  the  establishment  of  a  positive  pressure  not  causing  any 
reflux  under  ordinary  circumstances  owing  to  the  competence 
of  the  valves  at  the  orifice  of  the  former.  There  is  also  a  special 
mechanism  in  the  diaphragm  itself  to  further  the  lymphatic  flow 
of  the  abdomen,  as  first  shown  by  v.  Kecklinghausen^  and  shortly 
afterwards  by  others  in  Ludwig's  laboratory.-  In  the  central 
tendon  of  the  diaphragm  exist  two  sets  of  lymphatics,  a  super- 
ficial and  a  deep  set,  just  as  in  every  other  tendon  of  the  body. 
Each  contraction  of  the  diaphragm  furthers  the  flow  from  one  set 
to  the  other  and  from  them  into  the  larger  trunks  (as  already 
described  on  p.  27).  A  similar  arrangement  of  the  lymphatics  is 
found  in  the  intercostal  spaces  (Dybkowski  ■') . 

Increase  in  the  respiratory  function  goes  hand  in  hand  with 
increase  in  the  capacity  and  function  of  the  lungs  (excepting  in 
cases  of  emphysema,  when  improvement  brings  about  reduction 
in  their  capacity),  and  consequently  with  increase  in  the  amount 
of  oxygen  in  the  blood.  The  coronary  arteries  will  in  conse- 
quence bring  a  greater  quantity  of  nutrient  matter  to  the  heart, 
which  will  become  strengthened  from  this  cause,  as  well  as  from 
the  fact  that  the  pulmonary  and  systemic  circulations  are 
furthered.  Improved  respiration,  in  fact,  acts  beneficially  on  the 
body  as  a  whole. 

In  many  patients  the  respiratory  process  is  carried  on  defec- 
tively ;  often  the  upper  part  of  the  thorax  is  raised  while  the 
lower  part  does  not  move,  the  abdomen  being  drawn  in.  This 
is  particularly  the  case  with  women  addicted  to  tight  lacing.  In 
such  patients  the  whole  action  of  the  diaphragm,  and  with  it 
the  greater  part  of  circulatory  iniproveuient  in  the  veins  and 
lymphatics  below  the  thorax,  is  lost. 

It  is  unnecessary  to  consider  in  detail  the  practice  of  wearing 

'  "  Die  Lymphgefasse  und  ihre  Beziehuug  zum  Bindegewebe,"  1862  ;  "  Zur 
Pettresorption,"  in  Virchoio's  Archiv,  vol.  xxvi.,  1863,  p.  172,  &c. 

-See  Ludwig  and  Schweigger-Seidel,  "  TJber  das  Centrum  Tendineum  des 
Zwerchfells,"  in  Arbeitcn  a.  d.  Fliys.  Anstalt  zn  Leipzig,  1860,  pp.  174-181. 
Schweigger-Seidel  und  Dolgiel,  "  tjber  die  Peritonealhuhle  bei  Fruschen  und  ihrer 
Zusammenhang  mit  deni  Lymphgefassysteme  "  in  ibid,  1866,  p.  68,  &c.  Schweigger- 
Seidel,  "Die  Behandlung  der  thierischen  Gewebe  mit  Argentnitric,"  ibid.,  1866, 
p.  150. 

'  See  p.  84. 


GYMNASTIC  MOVEMENTS  127 

corsets  and  other  tight-fitting  garments,  as  so  much  has  ah'eady 
been  written  on  this  topic.  The  following  are  the  main  reasons 
for  condemning  it : — 

(a)  As  stated  above,  the  proper  return  of  the  lympii  and 
venous  blood  from  the  parts  below  the  thorax  is  hindered  and 
the  arterial  supply  to  them  diminished.  There  is  a  constant 
tendency  to  congestion  of  the  head  and  chronic  headache, 
specially  on  exertion ;  and  thus  the  subject  is  disposed  to  limit 
exercise  as  much  as  possible. 

(b)  The  anterior  abdominal  muscles  are  weakened  through 
lack  of  exercise. 

(c)  The  erector  spina'  muscles  are  also  weakened,  and  spmal 
curvatures  can  result  much  more  easily. 

(fZ)  The  organs  of  the  abdomen  proper  are  prevented  from^ 
properly  discharging  their  functions.  Deformations  of  the  liver 
from  tight  lacing  are  generally  accorded  a  paragraph  in  text-books 
on  pathology. 

(e)  The  pressure  on  the  pelvic  organs  and  the  tendency  to 
stasis  aid  powerfully  in  predisposing  to,  if  not,  indeed,  actually 
causing,  pelvic  disease,  with  a  detrimental  eifect  to  the  future 
generation.  From  unhealthy  reproductive  organs  come  unhealthy 
children.' 


Low  Sitting  Chest  Lifting  (Expansion),  PP. 

The  patient  assumes  the  low  sitting  position.  The  assistant,. 
standing  behind  and  supporting  the  patient's  back,  grasps  the 
upper  arms  as  in  fig.  ^2.  Then,  lifting  them  in  an  upward 
and  backward  direction,  he  causes  the  heads  of  the  humeri  to 
describe  a  circle  whose  direction  is  positive  as  seen  from  the 
right.  This  movement  should  be  executed  smoothly  and  evenly, 
and  repeated  with  a  pause  of  a  second  or  so  between  each  indi- 
vidual lifting  some  five  or  six  times.  During  the  elevation  of 
the  shoulders,  the  patient  should  inspire  deeply,  and  during  the 
reverse  movement  make  a  deep  expiration. 

The  chest  is  passively  enlarged  by  the  assistant,  and  still 
more  so  by  the  patient's  deep  respiration. 

'  Cf.  Hai'telius',  "  Siic/irlifvets  Skadliga  Inveikau,"  in  Tidskrift  i  Gljmimstik\ 
vol.  ii.,  1887,  p.  OCT. 


128    ELEMEXTS  OF  KELLGREN'S  MANUAL  TREATMENT 


Heave  Lean  Standing  Chest  Expansion,  PA. 

The  patient  assumes  the  heave  lean  standing  position  witli  his 
■chest  well  forward.     The  assistant,  standing  behind  him,  places 


GYMNASTIC  MOVEMENTS  129 

his  hands  on  the  scapulae,  and  by  applying  pressure  in  an  inward 
and  forward  direction  approximates  their  vertebral  borders,  and 
thus  helps  in  the  expansion  of  the  chest  (fig.  63).  The  patient 
then  rises  on  his  toes,  and  while  doing  so  takes  a  deep  inspiration 
and  leans  forwards  yet  more  by  contracting  his  posterior  scapular 
muscles,  so  as  to  still  further  expand  his  chest.  This  is  aided 
by  the  pressure  from  the  assistant  being  applied  in  an  increasing 
degree.  Then  the  patient  sinks  down  on  his  toes  again,  with 
deep  expiration,  and  the  pressure  from  the  assistant  is  somewhat 
relaxed  ;  while  sinking  down,  however,  the  patient  should  let 
his  forearms  move  a  little  downwards.  This  process  is  repeated 
three  times.  Last  of  all,  the  arms  are  moved  up  against  the 
poles  with  deep  inspiration,  until  stretch  lean  position  is  reached, 
and  then  adducted  with  deep  expiration. 

When  patients  are  unable  to  perform  this  exercise  without 
getting  the  back  lordosed  during  its  execution,  the  forearms  may 
be  kept  fixed  throughout,  instead  of  moving  downwards  after  each 
rising  on  the  toes. 

This  movement,  as  the  name  implies,  effects  expansion  of 
the  chest. 

Heave  grasp  standing  drawing  forwards,  PP,  the  eifect  of 
which  is  similar  to  the  above,  has  been  already  described  on 
p.  120. 

Two  other  respiratory  movements  may  conveniently  be 
described  here. 

Stretch  Grasp  Toe  Standing  Hanging,  Breathing,  PA. 

The  patient  assumes  heave  lean  standing  position,  and  then 
stretches  his  arms  as  high  as  possible  and  grasps  the  poles  firmly, 
rising  on  his  toes  while  doing  so.  He  thus  arrives  at  stretch 
grasp  toe  standing  position.  He  then  moves  his  feet  backwards 
on  the  ground  as  far  as  possible,  and,  remaining  in  this  position, 
supported  by  hands  and  toes,  with  body  hanging  quite  relaxed 
and  free  from  muscular  contraction,  takes  three  deep  respirations. 
After  this  he  executes  the  several  stages  of  the  movement  in  the 
reverse  direction  and  order  until  he  reaches  the  initial  position 
(fig.  64). 

A   stretching   of  the   whole   of   the   body,  especially   of   the 
abdomen,  takes  place,  the  chest  being  greatly  lifted;  this  move- 
ment is  especially  a  respiratory  one. 
9 


I30  ELEMENTS  01-    KELLGREN'S   MANUAL    TREATMENT 


Fig.  64^ 

Walk  Standing  Double  Arm  Circling,  Breathing,  PA. 

From  the  walk  staiuliiiL;  position  the  patient  hi'inga  his  amis. 
which  at  first  hang  veitically  downwards,  through  reach,  stretch, 
and  yard  positions  hack  to  the  original  position.  He  inspires 
deeplj'  during  the  first  half  of  the  movement  up  to  stretch  position  ; 
during  the  second  half  of  the  movement  a  deep  expiration  should' 
l)e  taken. 

This  exercise  is  a  respiratory  one.  In  cases  of  defects  in  the 
respiratory  or  circulatory  apparatus  (or  often  even  without  the 
existence  of  these)  it  should  take  place  after  every  active  gym- 
nastic movement.  In  the  latter  case  it  should  onlj'  be  executed 
once  each  time,  hut  as  a  separate  exercise  it  should  take  place 
three  times  with  one  foot  forwards,  and  then  three  times  with  the 
other. 

The  actual  movement  of  the  arms  is  circumduction  of  the 
shoulder-joint. 


GYMNASTIC  MOVEMENTS 


131 


LIFTING. 

Chest  lifting  has  been  desciibed  under  expansion  (p.  127). 
Anal  and  rectal  lifting  will  be  described  on  p.  233. 
Liftings  of  the  female  pelvic  organs  will   be  considered  on 
pp.  28.5-237. 

HEAD    LIFTING. 
Sitting  Head  Lifting,  PP. 

The  patient  assumes  the  sitting  position.  The  assistant 
places  one  of  his  hands  on  the  patient's  forehead,  and  the  thumb 
and  forefinger  respectively'  (or  else  the  whole  palmar  aspect)  of 
his  other  hand  on  each  side  of  the  occiput  just  below  the  superior 
curved  line. 

Performing  traction  of  the  hand  away  from  the  trunk,  the 
assistant  simultaneously  extends  the  head  a   little   backwards, 


132    ELEMENTS  OF  KELLGREN'S  .V A S U A L   TREATMENT 

after  which  he  lifts  up  the  posterior  part  and  flexes  it  a  httle 
forwards,  keeping  meanwhile  his  anterior  hand  as  still  as  possible. 
He  then  partially  releases  the  traction  upwards  and  brings  the 
patient's  head  to  the  vertical  once  more.  The  process  is  repeated 
several  times.  Particular  care  must  be  taken  to  flex  the  head  on 
the  cervical  vertebrae,  and  not  the  latter  on  one  another  (fig.  6.5). 

From  the  alternating  elongation  and  shortening  of  the  blood- 
vessels, the  circulation  through  the  brain  is  promoted,  just  as  in 
the  case  of  head  flexion,  PR,  and  extension,  AR  (p.  72).  The 
venous  return  is  also  furthered  by  the  special  anatomical 
mechanism  that  exists  in  the  attachment  of  the  walls  of  the 
internal  jugular  vein  to  the  sterno-mastoid  (see  p.  48) ;  this 
exercise  is  therefore  depleting  for  the  head.  The  actual  move- 
ment should  be  confined  to  the  occipito-atlantal  joint.  The 
cervical  part  of  the  spinal  column  is  stimulated,  as  is  also  the 
same  portion  of  the  spinal  marrow.  During  the  actual  lifting 
there  occurs  in  most  patients  some  dilatation  of  both  pupils. 


GYMNASTIC  MOVEMENTS  133 


SHAKING  AND  VIBRATION.     FRICTION. 

The  manipulations  specified  in  the  headnig  of  this  chapter 
are  most  conveniently  grouped  together ;  for  some  structures 
allow  of  frictions  and  vibrations  but  not  shakings,  while  others 
allow  of  shakiugs  and  vibrations  but  not  frictions,  and  so  on. 
This  division  of  the  subject  comprises  the  consideration  of  some 
of  the  most  important  manipulations  employed  by  Henrik 
Kellgren  in  the  actual  treatment  of  disease.  It  is  especially  by 
means  of  these  particular  manipulations  that  such  conditions  as 
acute  specific  infectious  fevers  are  brought  within  the  effective 
range  of  the  manual  treatment,  and  that  so  much  more  can  be 
accomplished  in  such  cases  than  is  possible  through  any  other 
method  whatever. 

A  few  of  the  forms  of  Henrik  Kellgren's  shakings  and  vibra- 
tions and  a  good  many  of  his  nerve  frictions  and  vibrations  have 
been  described  in  the  works  of  Arvid  Kellgren.'  These  I  shall 
re-describe  in  my  own  words  ;  and  in  addition  I  shall  enter  into 
details  concerning  many  other  forms  used  by  Henrik  Kellgren 
which  have  hitherto  not  been  described. 

SHAKING. 

Two  or  more  digits  (with  or  without  the  palm)  are  placed 
with  their  palmar  aspect  against  the  part  to  be  treated,  and 
remain  in  such  contact  throughout  the  manipulation ;  the  joints 
of  the  fingers,  wrist,  and  elbow  are  kept  as  loose  as  possible 
compatible  with  the  correct  execution  of  the  movement.  A  rapid 
alternating  contraction  and  relaxation  of  some  of  the  muscles  of 
the  forearm  in  whole  or  in  part,  sometimes  with  co-action 
of  the  muscles  of  the  upper  arm,  is  then  set  up.  (An  excep- 
tion is  found  in  "  gentle  "  shakings,  in  which  the  muscles  of  the 
forearm  are  passive,  the  movement  involving  only  some  of  the 
shoulder-joint  muscles.)     The  actual  excursion  of  the  movement 


'"Vortnige    uber    Massage,"    iu    "  Statistischer   Sanitiitsbericht  ...  fiir  1888," 
pp.  163,  &c.,  and  "Technic  of  Liug's  System  of  Maoual  Treatment,"  1890. 


134    ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

at  the  wrist-joint  in  administering  shaking  varies  under  ordinar}' 
circumstances  from  ahout  one-eighth  of  an  inch  to  one  inch. 
The  amount  of  muscular  force  employed  should  be  minimised 
whether  the  amplitude  of  the  movement  be  large  or  small ; 
otherwise  the  manipulation  will  become  hard,  jerky,  and  irreg- 
ular, instead  of  being  soft,  elastic,  and  regular.  The  part  under 
treatment  is  subjected  to  a  series  of  rapid,  wavelike  movements 
of  alternating  application  and  removal  of  pressure.  Were  the 
assistant's  hand  removed  with  each  relaxation,  the  part  in 
question  would  not  be  shaken,  but  instead,  subjected  to  a  series 
of  strokes  resembling  clapping  (see  pp.  197,  &c.). 

The  following  are  the  various  forms  of  shaking  :  — 
I. —  Up  and  down. 

(1)  Gentle. 

(2)  Medium. 

(3)  Strong. 

II. — Side  to  side. 

(1)  Gentle. 
('2)  Medium. 

Ul.—Bof  atari/. 

1. — Shafting   Up  and  Doion. 

This  is  by  far  the  most  usual  form. 

(1)  Gentle. — Is  given  from  the  finger  and  wrist-joints,  which 
are  alternately  passively  flexed  and  extended  by  means  of 
alternating  external  and  internal  rotation  of  the  shoulder- 
joint. 

(2)  Medium. — Is  given  from  the  same  joints  but  the  finger 
and  wrist-joints  are  alternately  actively  flexed  and  extended. 
The  amount  of  pressure  applied  is  greater. 

(8)  Strong. — Is  given  chiefly  from  the  wrist  and  shoulder- 
joints  ;    the  amount  of  pressure  applied  is  proportionately  greater. 

Examples. — The  first  kind  is  illustrated  by  heart-shaking 
(p.  190),  the  second  by  subcostal  shaking  (p.  192).  The  thn-d 
kind  is  not  often  resorted  to,  but  may  be  used  in  certain  cases 
calling  for  very  strong  stimulatory  treatment. 


G  YMNA  STIC    MO  YEMEN TS 


135 


II. — Shaklii'j  from  Side  to  Side. 

This  is  a  method  not  often  employed. 

(1)  Gentle. — Is  given  by  means  of  alternating  radial  and  ulnar 
flexion  of  the  wrist-joint,  the  elbow-joint  being  kept  as  still  as 
possible. 

(2)  Medium. — Is  given  by  the  same  muscles  (radial  and  ulnar 
flexors)  as  (1),  but  the  wrist-joint  is  kept  as  still  as  possible;  thus 
the  movement  chiefly  takes  place  in  the  elbow-joint. 

Example.';. — These  manipulations  are  sometimes  resorted  to 
on  the  head  or  over  muscles. 


III. — Rotatory   ShaJciurj. 

This  is  a  method  employed  to  administer  the  passive  move- 
ments of  rotation  at  the  wrist-joint,  or  of  pronation  and  supination 
at   the   radio-ulnar  joints,   in   the   case   of   stiffness,    &c.      The 


^AM/W\MM/WW\/W\AAAAA/WWVW\AA/^^ 


Fig.   G6. 
Time  tracing,  every  two  seconds. 


assistant,  having  grasped  the  hand  of  the  patient  in  his  own, 
causes  it  to  undergo  a  rapid  alternating  pronation  and  supination. 
If  his  other  hand  be  used  to  fix  the  patient's  forearm  just  above 
the  wrist,  the  movement  is  transmitted  exclusively  to  the  wrist- 
joint  ;  if,  however,  the  patient's  forearm  be  not  fixed,  but  only 
the  upper  arm,  the  radio-ulnar  joints  are  instead  affected. 

The  rate  at  which  shakings  are  administered  may  vary  con- 
siderably ;  the  maximum  compatible  with  regularity  over  a  long 
space  of  time  is  about  7  per  second. 

Figs.  66  and  67  give  graphic  representations  of  shakings. 
The  records  were  made  by  means  of  an  indiarubber  ball  placed 


136    ELEMEXTS  OF  KELLGREK'S  MANUAL   TREATMENT    ■ 

under  the  palm  of  the  hand  that  administered  the  shakings. 
Every  up  and  down  movement  of  the  pahn  caused  air  to  be 
alternately  drawn  in  and  sent  out  of  the  ball ;  the  variations  in 
the  volume  of  the  latter  were  recorded  by  means  of  a  Marey's 
tambour  which  was  connected  to  it  by  means  of  a  tube. 

Fig.  66  represents  shaking  from  the  wrist  and  finger-joints. 
Fig.  67  represents  shaking  from  the  wrist  and  shoulder-joints. 


Fig.  07. 
Time  tracing,  everj'  two  seconds. 

VIBEATION. 

The  method  of  executing  vibrations  is  similar  to  that  described 
under  the  heading  of  shakings,  but  the  excursion  of  the  move- 
ment being  smaller,  a  series  of  waves  of  considerably  less 
amplitude  and  gi-eater  frequency  is  set  up  in  the  part  that  is 
being  treated.^  Vibrations  are  produced  by  alternate  contraction 
and  relaxation  of  antagonistic  groups  of  muscles  or  of  the  same 
set  of  muscles.  The  actual  excursion  of  the  movement  at  the 
metacarpo-phalangeal  and  wrist-joints  varies  under  ordinary  cir- 
cumstances from  one-twentieth  to  one-eighth  of  an  inch.  The 
amount  of  muscular  force  employed  should,  just  as  in  shakings, 
be  minimised;  with  a  gentle  vibration  the  contraction  of  the 
flexors  of  the  forearm  should  be  only  just  perceptible  to  the 
sense  of  touch  of  another  person. 


'  Cf.  Wide,  "  Handbook  of  Medical  and  Oithopiedic  Gymnastics,"  1903,  p.  73, 
who  says — "Vibration  ....  is  a  weaker  movement,  so  that  tlie  part  of  body 
in  question  does  not  undergo  any  real  shaking,  but  remains  at  rest,  whilst  a  shak- 
ing uxjon  the  same  is  made."  See  also  "  Handbok  i  Medicinsk  Gymnastik,"  1895, 
p.  66;  "Handbook  of  Medical  Gj'mnastics,"  1899,  p.  65;  "Handbok  i  Medicinsk 
och  Ortopedisk  Gymnastik,"  1903,  p.  63. 


GYMXASTIC  MOVEMENTS  137 

The  following  are  the  various  forms  of  vibration  : — 

(A)     Simple  Forms. 

(A)  Stationary. 

I. — Up  and  doivii. 

(1)  Generated  from  tinger-joints. 
(«)  Very  fine. 

(b)  Fine. 

(2)  Generated  from  wrist  and  fiuger-joints. 

(a)  Gentle. 

(b)  Medium. 

(c)  Strong. 

(i.)  With  pressure  apphed  from  the  elbow- 
joint. 

(ii.)  With  pressure  applied  from  the  shoulder 
and  elbow  joints. 

(d)  Very  strong,  called  pressure  vibration. 

(8)  Generated  from  elbow-joint, 
(rt)  Medium. 
{b)   Strong. 

(4)  Generated  from  shoulder-joint,  X-c.  (?) 
II. — Side  tu  side.     Generated  from  wrist-joint. 
III. — Botatori/.     Generated  from  radio-ulnar  joints. 

(B)  KUNNING. 

l.—Slow. 

(1)  Light. 

(2)  Strong. 
II. — Ra2>id- 

(1)  Light. 

(2)  Strong. 

(B)     Complex    Forms. 

(1)  Suction  vibrations. 

(2)  Dispersing  vibrations. 

(3)  Nipping  vibrations. 


I3S    ELEMENTS  OF  KELLGREN'S    MANUAL   TREATMENT 

(A)     Simple    Fonms. 

(A)    Stationary  Vibrations. 

Are  executed  by  one  or  more  phalanges  of  one  or  more 
digits,  which,  having  been  placed  with  the  palmar  aspect  on  the 
part  to  be  treated,  set  up  a  continuous  vibration  on  the  same 
spot. 

I. — U}}  and  Down   Vibrations. 
The  movement  may  be  generated  from  : — 

(1)  The  finger-joints. — The  movement  is  performed  by  the 
flexors  of  the  fingers,  the  wrist-joint  participating  as  little  as 
possible.  («)  If  the  excursion  of  the  movement  be  kept  to  the 
minimum,  there  will  result  the  most  minute  vibrations  possible ; 
these  I  have  expressly  termed  "  very  fine."  (b)  A  slightly  larger 
excursion  will  proportionately  increase  the  amplitude  of  the  vibra- 
tions, which,  however,  can  still  be  termed  "fine."  Such  "very 
fine  "  and  "  fine  "  vibrations  may  be  used  in  cases  requiring  great 
delicacy  of  manipulation,  e.g.,  in  acute  conditions  of  the  eyes. 

(2)  The  wrist  and  finger  joitits. — If  the  wrist-joint  be  allowed 
to  participate  as  well  as  the  finger-joints,  then  the  flexors  of  both 
the  wrists  and  fingers  will  be  in  action,  (a)  The  "  gentle  "  vibra- 
tions are  produced  by  the  excursion  of  the  movement  and  the 
pressure  applied  being  kept  at  the  minimum,  (h)  "Medium" 
ones  are  produced  by  an  increase  in  both,  (c)  "  Strong "  are 
produced  by  a  still  further  increase.  The  pressure  is  in  every 
case  applied  from  the  elbow-joint  by  means  of  contraction  in  the 
triceps,  the  shoulder  being  fixed. 

The  method  just  described  is  the  most  usual  one  of  executing 
vibrations,  and  is  employed  unless  indications  exist  for  producing 
them  in  a  different  way. 

(d)  For  the  "  very  strong  "  or  "pressure"  vibrations,  the  tip 
of  the  thumb  is  used,  the  forefinger  being  applied  to  it  so  as 
to  steady  it.  It  is  placed  on  the  part  to  be  treated  and  then 
vibrates  while  simultaneously  strong  pressure  is  applied.  This 
manipulation  is  generally  maintained  for  only  a  few  seconds  at  a 
time ;  it  is  employed  for  some  deep-seated  nerves,  such  as  the 
great  sciatic  in  the  buttock,  in  cases  where  powerful  stimulation 
IS  required. 


GYMNASTIC  MOVEMENTS  139 

(3)  The  elhoio-joint. — When  it  is  ueces'sSiy  to  lift  a  structure 
and  then  vibrate  it,  the  manipulation  is  termed  a  "lift-vibration," 
and  is  generally  given  with  the  movement  generated  from  the 
elbow-joint  (see  uterine  lift-vibration,  p.  237).  The  flexors  and 
extensors  of  that  joint  are  the  muscles  placed  in  action.  Accord- 
ing to  the  amplitude  of  the  movement  the  vibrations  are 
"medium"  or  "strong."  This  form  of  yjbration  is  also  found 
in  the  bitemporal  movement  (p.  217). ,      , :  : 

(4)  The  shoulder,  elbow,  and  zvrist  joints. r— In  certain  very  rare 
cases,  where  strong  stimulation  becomes  necessary,  the  vibration, 
with  simultaneous  pressure,  may  be  generated  from  all  the  joints 
of  the  arm.  This  method,  however,  should  never  be  employed 
on  nerves '  under  any  circumstances,  as  it  to  a  great  extent 
eliminates  the  tine  sense  (jf  touch.  It  is,  moreover,  extremely 
tiring,  and  cannot  be  continued  with  evenness  and  regularity  for 
more  than  a  minute  or  so. 

II.— Side  to  Side   Vibrations. 

Are  executed  by  a  rapid  alternating  radial  and  ulnar  flexion 
of  the  wrist,  the  elbow  being  kept  still.  They  may  be  employed 
when  treating  the  head. 

III. — Rotator ij   Vibrations. 

Are  given  in  the  same  manner  and  for  the  same  conditions  as 
rotatory  shakings,  but  the  movement  is  a  much  finer  one,  the 
amplitude  being  much  smaller. 

(B)  RuxxiXG  Vibrations. 

During  the  course  of  a  running  vibra,tion  the  vibrating  digit  or 
digits,  instead  of  remaining  continually  on  one  spot,  are  moved 
along  a  structure  in  the  line  of  its  long  axis.  Either  the  soft 
parts  of  the  distal  phalanges  of  the  forefingers  and  thumb  or  el.se 
the  backs  of  the  nails  of  one  or  more  fingers  are  employed. 
According  to  the  speed  and  strength  with  which  running  vibra- 
tions are  executed  they  are  classified  into  "slow"  and  "rapid" 

'  Tokaroff  erroneously  supposes  that  this  is  the  method  ordinarily  employed  by 
Henrik  Kellgren  in  treating  nerves ;  see  "  Nervenvibrationen,  eine  neue  manuelle 
Behandlungsmethode,"  in  Allgem.  Wien.  Med.  Zeit.,  1888.  See  also  Reibmayr, 
"  Die  Techuik  der  JIassage,"  1898,  p.  29. 


I40    ELEMEXTS  OF  KELLGREN'S  MANUAL   TREATMENT 

forms,  either  of  which  may  he  "  hght  "  oi'  "  strong."  The  slow 
form  is  sometimes  called  a  vibratory  stroking,  if  used  as  a 
substitute  for  stroking  over  an  cedematous  or  congested  area  {see 
pp.  180,  205). 

(B)     Complex   Forms. 

(1)  Suctivn  vibrations. — These  are  made  use  of  when  it  is  desired 
to  prevent  absorption  by  the  tissues  and  to  concentrate  lymph  in 
the  part,  to  favour  pointing  of  an  abscess,  &c.  The  fingers  and 
thumb  are  spread  well  out  round  the  area  to  be  treated,  as  in 
fig.  68 ;  then,  being  set  into  vibration,  the  metacarpo-phalangeal 
and   interphalangeal-joints    are    flexed   so  that  the  fingers   and 


thumb,  which  move  as  one  with  the  skin  of  the  patient,  are 
approximated  to  one  another,  a  certain  amount  of  pressure  being 
meanwhile  applied.  With  the  extension  of  the  joints  of  the 
fingers  and  thumb  the  pressure  is  removed,  or  the  digits  may 
be  lifted  right  off  the  part  until  they  are  again  in  the  original 
position,  when  the  movement  is  repeated. 

(2)  Dispersing  vibrations. — These  are  made  use  of  when  it  is 
desired  to  favour  absorption  from  small  effusions,  &c.  They  differ 
from  the  above  (1)  in  this  respect  that  the  pressure  is  applied 
during  the  extension  of  the  fingers  and  thumb,  and  removed 
during  the  flexion. 

(3)  Nipping  vibrations. — These  are  used  in  connection  with 
certain  skin  diseases  in  order  to  cause  a  gentle  exudation  of  the 


GYMNASTIC  MOVEMENTS  141 

contents  of  the  catarrhal  cells  of  the  skin.  The  skin  is  gently 
pinched  between  the  forefinger  and  thumb,  which  vibrate  simul- 
taneously. 

Vibrations  may  be  administered  with  varying  speeds,  the 
maximum  being  about  12  per  second,  the  minimum  about  6  per 
second.'  Figs.  69  and  70  give  graphic  representations  of  vibra- 
tions.    Fig.  69  represents  vibrations  generated  from  the  fingers, 


Fio.    G9. 
Time  tracing,   every  two  secoads. 


Fig.    70. 
Time  tracing,   every   two   seconds. 

the  wrist-joint  not  participating.  The  method  of  recording  was 
by  means  of  an  indiarubber  ball,  as  described  on  p.  135,  but  placed 
under  the  finger-tips  instead  of  under  the  palm.  The  rate  can  be 
seen  to  be  about  12  per  second.  In  fig.  70,  with  the  indiarubber 
ball  in  the  same  position,  vibrations  from  the  wrist  and  finger- 
joints  are  represented,  the  rate  being  slightly  less  than  7  per 
second. 

'  Reibmayr  erroneously  gives  the  number  of  vibrations  according  to  Kellgren's 
method  as  200-300  per  minute  {vide  "  Die  JIassage  und  ihre  Verwerthung  in  den 
verschiedenen  Disciplinen  der  Praktischen  Medicin,"  1893,  p.  14,  and  "Technik 
der  Massage,"  1898,  p.  32).  Saquet  gives  even  a  lower  estimate,  i.e.,  "hardly 
more  than  200  a  minute  "  (vide  "  De  la  trepidation  mecanique  locale  ou  vibration," 
1898,  p.  2.  Also  Lavalette  "  De  la  sismotherapie,"  These  de  Paris,  1899).  Hj.  Ling 
states  that  shakings  and  vibrations  have  a  speed  of  about  1,000  per  minute  {vide 
"  De  Forsta  Begreppen  af  Riirelselaran,"  18G6,  p.  149,  and  "  F.irkortad  Ofversigt  af 
.\llman  Borelselara, "  1880,  p.  71). 


142    ELEMEXTS  UF  KELLGREX'S  MANUAL   TREATMENT 

•■  FllICTION. 
(A)  Nerve  Friction. 
The  nerve  to  be  treated  must  first  of  all  be  exactly  located,  if 
possible  by  the  sense  of  touch.'  Any  muscles  or  other  structures 
that  lie  over  the  nerve  must  be  uncontracted  and  relaxed.  The 
fingers  are  then  drawn  sharply  across  the  nerve  as  much  as 
possible  at  right  angles  to  its  long  axis.  The  manipulation 
causes  the  nerve  in  question  to  be  set  into  vibration.  In  the 
case  of  deep-seated  nerves  the  fingers  move  in  unison  with  the 
structures  that  lie  over  the  nerves.  In  the  case  of  cutaneous 
nerves,  however,  the  fingers  are  moved  across  the  skin  in  which 
they  lie. 

The  following  are  the  various  forms  of  nerve  friction  : — 

(A)     Simple   Forms. 

(A)  St.\tionaey. 

\.—Sloic. 

(1)  Light. 
(■2)  Medium. 

(3)  Strong. 

(4)  Very  strong  (called  "pressure  friction"). 
II. — Rapid. 

(1)  Light. 

(2)  Medium. 
(8)   Strong. 

(B)  Running. 

I. — Slow. 

(1)  Light. 

(2)  Medium. 

(3)  Strong. 
II. — Rapid. 

(1)  Light. 

(2)  Medium. 

(3)  Strong. 

'  Reibmayr  denies  the  possibility  of  being  able  to  feel  a  nerve  {vide  "Die  Massage 
und  ihre  Verwerthuiig  in  den  verschiodeuen  Disciplinen  der  Praktischen  Medicin," 
1893,  p.  16,  and  "  Die  Teclinik  der  Massage,"  1898,  p.  28,  &c.)  The  only  explana- 
tion of  this  is  that  either  Reibmayr  never  tried  to  feel  the  ulnar  nerve  at  the  elbow, 
the  facial  nerve  as  it  comes  round  the  angle  of  the  jaw,  or  the  brachial  plexus  in 
the  axilla,  &c.,  or  else  he  really  failed  to  feel  them  after  careful  endeavour. 


GYMNASTIC  MOVEMENTS  143 

(B)     Complex    Forms. 

(1)  Friction  vibrations. 

(2)  Friction  vibrations  with  suction. 

(A)     Simple  Forms. 

(A)     Stationary  Nerve   Frictions. 

Are  executed  in  the  manner  just  described,  and  if  repeated 
take  place  at  precisely  the  same  point  in  the  course  of  the  nerve. 
They  may  be  repeated  at  either  a  slow  or  a  rapid  rate.  If  it  is 
desired  to  render  them  "light,"  "medium,"  or  "strong,"  the 
variation  is  produced  by  the  distal  phalanx  of  one  or  more  fingers 
with  or  without  pressure  from  the  elbow-joint.  "  Pressure 
frictions,"  on  the  other  hand,  are  administered  in  the  same 
manner  as  pressure  vibrations,  frictions  being  substituted  for 
the  vibrations. 

(B)     KuxxiNCi  Nerve  Frictions. 

May  be  administered  with  the  distal  phalanges  of  two  or  more 
fingers,  or  else  with  the  tips  of  the  forefinger  and  thumb  placed 
in  apposition.  The  method  is  the  same  as  for  stationary  nerve 
frictions ;  but  the  fingers,  instead  of  repeating  the  friction  at  the 
same  point  of  a  nerve,  are  moved  either  up  or  down  the  nerve 
trunk,  so  that  the  frictions  take  place  at  different  points  of  its 
course.  Such  running  nerve  frictions  maj'  be  repeated  at  either 
a  slow  or  a  rapid  rate  ;  and,  according  to  the  amount  of  pressure 
applied,  they  are  termed  "  light,"  "  medium,"  or  "  strong." 

(B)     Complex    Forms. 

(1)  Friction  vibrations. — While  either  medium  or  strong  up 
and  down  vibrations  are  administered  the  fingers  are  simul- 
taneously used  to  execute  small  frictions.  This  manipulation  is 
used  on  the  head,  and  also  at  the  margins  of  ulcers  in  order  to 
stimulate  the  cutaneous  nerves. 

(•2)  Friction  vibrations  with  suction. — These  are  executed  in 
the  same  manner,  suction  vibrations  being  substituted  for 
ordinary  vibrations.  They  are  used  in  the  treatment  of  dis- 
charging abscesses,  i!i:c. 


144     ELEMENTS   OF  KELLCREN'S  MANUAL    TREATMENT 

Whether  a  stationary  or  a  running  friction,  or  a  stationary 
or  a  running  vibration  be  administered  on  a  nerve,  the  nerve  is 
set  into  vibration.  I  venture  to  propound  the  following  as  the 
possible  explanation  from  a  physical  point  of  view  of  the  different 
physiological  effects  resulting  from  different  methods  of  nerve 
treatment ; — 

A  friction  across  a  nerve  causes  torsional,  transverse,  and,  to 
a  less  extent,  longitudinal  vibrations  in  it.  A  running  vibration 
or  friction  along  a  nerve  causes  longitudinal  and,  to  a  less  extent, 
transverse  vibrations  in  it.  Vibrations  given  continuously  on 
the  same  spot  on  a  nerve  cause  transverse  and,  to  a  slight  extent, 
longitudinal  vibrations  in  it.  From  the  very  nature  of  all  these 
manipulations  the  venous  and  lymph  return  in  and  around  the 
nerves  will  be  promoted.  It  has  also  been  established  by 
experiment  that  certain  kinds  of  vibrations  stimulate  nerves  if 
administered  with  sufficient  intensity.' 

The  precise  effect  of  vibrations  and  frictions  on  nerves  will 
be  considered  on  pp.  149,  &c. 

(B)     Frictions  on  other  Structures. 

The  modus  operandi  of  these  will  be  discussed  on  pp.  194,  &c. 
For  purposes  of  convenient  description  the  shakings,  vibra- 
tions, and  frictions  will  be  divided  into  three  groups  : — 

I. — Vibrations  and  Frictions  on  Nerves  and  Ganglia. 
11. — Vibrations  and  Shakings  on  Other  Structures. 
III. — Frictions  on  Other  Structures. 

I.- — Vibrations  and  Frictions  on  Nerves  and  Ganglia. 
History  and  development. — A  kind  of  nerve-pressing  was  used 
by  P.  H.  Ling^  {cf.  Sonden,^  Georgii,^) ;   he  also  employed  nerve 

'  See  Langendorff,  "  tjber  Tetanisirung  von  Nerven  durch  rhythmische  Dehnung," 
iu  Centralbl.f.  d.  Med.  Wissensch.,  Feb.  15,  1882,  pp.  113-115.  Axenfeld,  "  Vibra- 
tiouen  der  Stimmgabel  als  Nervemeiz,"  Cc)^(^■ai6i.  /.  Fltysiologie,  1892,  vol.  vi., 
pp.  299-300.  Uexkull,  "  Zur  Methodik  der  meclianischen  Nervenreizung,"  Zeitsdtr. 
f.  Biologic,  vol.  xxxi.,  pp.  148-167;  "  Uber  Erschiitterung  und  Eutlastung  der 
Nerven,"  ibid.,  vol.  xxxii.,  pp.  438-445.  "  Zur  Muskel  und  Nervenphysiologie  von 
Sipunculus  Nudus,"  ibid.,  vol.  xxxiii.,  pp.  1-27.  "Der  Neurokinet;  ein  Beitrag  zur 
Theorie  dermechanischen  Nervenreizung,"  ibid.,  vol.  xxxviii.,  pp.  291-299.  Boruttau, 
"  Weitere  Erfahrungen  iiber  die  Beziebung  des  N.  Vagus  zur  .\tbmung  und  Ver- 
danung,"  Archiv  f.  Physiologic,  vol.  Ixv.,  p.  26;  also  Schafer,  "A  Simple  Apparatus 
for  the  IMechanical  Stimulation  of  Nerve,"  in  Journ.  of  Phys.,  vol.  xxvi.,  pp.  xxii., 
xxiii. 

-  "  Gymnastikens  AUmiinna  Grander,"  1834  (1840),  p.  71,  (1834)  1840,  pp.  15.3,  &c. 

'  "  Tankar  ofver  praktisk  Medicin,"  in  Hygein,  1840,  JIareb  No.,  p.  122. 

'  "  Kinetic  Jottings,"  1880,  p.  73. 


GYMNASTIC  MOVEMENTS-  145 

strokings.'  Brantiug,  in  1844,  referred  to  phrenic  and  lumbar 
nerve  pressings  as  being  something  new  - ;  in  1846  similar 
manipulations  on  the  spinal  accessory  and  sacral  nerves  were 
advocated  by  him.^ 

A  few  years  later  nerve  pressings  with  or  without  simultaneous 
trembling  movement  were  used  a  good  deal;  sometimes  blunt 
pointed  sticks  were  employed  by  the  operator  in  the  case  of  deep- 
seated  nerves.  The  modus  operandi  is  described  by  Eothstein,* 
Neumann,^  Eoth,"  and  Eulenburg,'  and  is  referred  to  in  several 
writings  of  the  latter,*  as  well  as  in  those  of  Georgii,'  de  Betou,"* 
Blundell,"  Branting,'-  and  Hj.  Ling.'^  Georgii'*  makes  one 
reference  to  a  "  friction  plus  ou  moin  legere  sur  le  trajet  d'un 
nerve,"  and  Eoth '^  to  a  "friction  along  the  course  of  a  certain 
nerve"  ;  but  such  manipulations  are  not  described  by  them,  and 
the  term  is  not  mentioned  by  them  elsewhere,  nor,  I  believe,  in 
any  of  the  works  of  the  other  authors  above  mentioned.  The 
method  with  sticks  was  after  a  time  abandoned  as  useless,  and 
even  the  manual  nerve  pressing  became  of  infrequent  use,  the 
benefit  obtained  being  inconsiderable.  The  enthusiastic  Neu- 
mann, who   in    1852   said,   concerning   direct  nerve   treatment : 


'  "  Gymuastikeus  Allmaaua  Gruuder,"  1866,  pp.  583-584. 

-Address  to  the  Graduates  of  the  G.  C.  I.,  delivered  on  April  1,  1844. 

'Address  to  tlie  Graduates  of  the  G.  C.  I.,  delivered  ou  April  1,  1846.  See  also 
Bock,  "  Lehrbuch  der  Pathologischen  Anatomie,"  1847,  p.  572. 

' "  Die  Gymnastik  nach  dem  System  des  Schwedischen  Gyrunasiarchen,  P.  H. 
Ling,"  1847,  pp.  67,  &c. 

*"Die  Heilgymnastik,"  1852,  pp.  211,  6ic.  "Lehrbuch  der  Leibesiibungen  des 
Jlenschen,"  1856,  pt.  ii.,  pp.  265,  &c. 

'  "  Handbook  of  the  Movement  Cure,"  1856,  pp.  178,  &c. 

'  "  Die  Heilung  der  chronischeu  Unterleibsbeschwerden,"  1856,  pp.  42,  &c. 

^ "  Mittheiluugen  aus  dem  Gebiete  der  Schwedischen  Heilgymnastik,"  1854, 
p.  34. 

" "  Kinesith^rapie,"  1847,  p.  54;  ."Kinetic  Jottings,"  1880,  pp.  73,  81,  93, 
160,  161. 

""'Therapeutic  Manipulation,"  1851,  p.  11. 

"  "  Medicina  Meohanica,"  1852. 

'■•  "  Address  to  the  Graduates  of  the  G.  C.  1.,  April  1,  1844,  and  April  1,  1846 
"  Efterlemuade  Skrifter,"  1882,  pp.  178,  &e. 

'^"DeFiirstaBegreppen  af  Rcirelseliiran,"  1866;  "  Forkortad  Ofversigt  af  Allman 
Riirelselara,"  1880,  in  which  repeated  references  are  made.  See  also  his  preface  to 
Branting's  "  Eft3rlemnade  Skrifter,"  1882,  pp.  xxxi. ,  xxxii. 

"  "Kinesitherapie,"  1847,  p.  54. 

'^"  Handbook  of  the  Movement  Cure,"  1856,  p.  6. 

10 


146  ELEMENTS   OF   KELLGREX'S   MANUAL    TREATMENT 

"  This  is  a  part  of  the  movement  cure  which  up  to  the  present 
has  been  least  developed  by  Ling's  pupils,  although  they,  espe- 
cially Branting,  quite  well  recognise  the  fact  that  it  ought  to  be 
one  of  the  most  important  parts," '  in  1856  made  the  following 
statement  about  nerve  pressings  :  "  For  my  part  I  now  consider 
that  these  manipulations  .  .  .  can  quite  well  be  dispensed  with, 
as  they  can  with  advantage  be  entirely  replaced  by  duplicate 
concentric  movements."  - 

Hartelius,  at  the  time  when  electrical  treatment  was  so  much 
vaunted,  combined  it  with  medical  gymnastics,  but  his  experience 
led  him  to  the  conclusion  that  medical  gymnastics  given  alone 
were  productive  of  greater  benefit ;  he  even  in  some  cases  found 
that  electricity  had  the  effect  of  destroying  the  improvement 
effected  by  medical  gymnastics.  So  electricity  was  not  used  any 
longer,  and  nerve  pressing  also  fell  into  disuse.  In  the  whole 
of  Hartelius's  "  Liirobok  i  Sjukgymnastik  "  '  the  only  descriptions 
of  nerve  manipulations  are  those  of  arm  and  leg  nerve  pressing, 
to  which  hardly  twenty  lines  are  allotted  ;  as  regards  other  nerves, 
a  few  of  them  (trigeminal,  facial,  vagus,  phrenic,  intercostal,  great 
sciatic)  *  are  casually  referred  to. 

Meanwhile,  however,  Henrik  Kellgren,  in  the  early  days  of 
his  practice  {circa  1865-1868)  elaborated  his  own  methods  of 
friction  and  vibration  for  the  purpose  of  directly  stimulating  and 
soothing  nerves,  and  in  the  late  sixties  he  was  using  the  new 
methods  with  great  success.  Gradually,  in  the  course  of  years, 
many  medical  men  came  to  hear  of  them,  but  reliable  information 
w'as  disseminated  slowly  owing  to  the  fact  that  Kellgren  himself 
refrained  from  publishing  any  details,  and  those  of  the  profession 
who  were  interested  lacked  the  practical  knowledge  and  technique, 
without  which  it  was  impossible  to  write  any  accurate  accounts. 
Amongst  those  who  referred  to  the  subject  may  be  mentioned 
Drs.  Wretlind  and  Glatter.  The  former,  himself  a  graduate  of 
the  G.  C.  I.,  spoke  in  1873  of  Kellgren's  nerve  treatment  as 


'  "  Die  Heilgymuastik,"  1852,  p.  359  (translated). 

-  "  Lehrbuch  der  Leibesiibungen,"  1856,  pt.  ii.,  pp.  265,  266  (translated). 

'  1st  Edition,  1870,  pp.  88  &  89.  2nd  Edition,  1883,  pp.  90  &  91.  3rd  Edition, 
1892,  pp.  88  &  89. 

'  See  also  Hartelius,  "  De  Fysiska  Lifsyttringarna  hos  Mennisljan,"  1868, 
pp.  120,  &c. ;  "  Om  Sjnkgj-mnastiska  Rcirelsers  Verkan  och  Anvandning,"  in 
Tidskrift  i  Gymnastil;  vol.    ii.,  1890,  pp.  201,  202. 


GYMNASTIC     MOVEMENTS  147 

something  new.^  Glatter,  writing  in  1875,  refers  to  Kellgren's 
nerve  treatment  as  applicable  to  pneumonia. - 

In  February,  1888,  Prof,  von  Nussbaum,  at  a  lecture  given  by 
him,  said  (translated):'  "At  the  present  moment  very  great 
attention  is  being  awakened  at  a  'Kuranstalt,'  where  Kellgren  in 
various  nerve  diseases  selects  the  affected  nerves  and  gives  passive 
movements  called  nerve  vibrations,  thereby  obtaining  results  which 
are  so  striking  that  the  scientific  world  cannot  but  take  notice  of 
them.  These  nerve  vibrations  are,  beyond  doubt,  a  new  and 
great  cure  for  nervous  diseases." 

In  1888  Arvid  Kellgren,  during  his  course  of  sixteen  demon- 
strations given  at  Pola  in  the  winter  of  1888-1889,  gave  the  first 
detailed  account  of  some  of  his  brother's  nerve  frictions  and  vibra- 
tions. It  was  published  in  "  Vortrage  iiber  Massage,"  1888,''  and 
his  "  Technic  of  Ling's  System  of  Manual  Treatment,"  1890. 

In  the  winter  of  1886-7  Dr.  A.  Levin  of  the  G.  C.  I.  visited 
Henrik  Kellgren  and  returned  to  Stockholm  with  a  certain 
amount  of  theoretical  and  practical  knowledge  of  Kellgren's 
nerve  treatment.'  His  return  to  that  city  was  promptly  followed 
by  a  communication  at  a  meeting  of  the  Stockholm  Gymnastic 
Association  from  A.  Wide  on  nerve  pressing''  and  a  paper ^  develop- 
ing his  views.  Wide  had  never  before  published  anything  con- 
cerning this  branch  of  the  subject,  but  now  emphasised  the 
importance  of  the  new  manipulations. 

In  his  paper  "  Om  Nervtryckning,"  and  in  "  Handbok  i  Medi- 
cinsk  Gymnastik,"  1896*  and  "Handbok  i  Medicinsk  och 
Ortopedisk  Gymnastik,"  1902-3,"  Wide  gives  a  list  of  the  nerves 
most  commonly  pressed.  In  "  Handbook  of  Medical  Gymnastics," 
1899,  and  "  Handbook  of  Medical  and  Orthopaedic  Gymnastics," 
1903,  which  are  somewhat  abridged,  this  list  is  omitted,  showing 
that,  after  all.  Wide  must  assign  to  these  manipulations  a  very 
unimportant  position. 

'  "  Bref  fran  Dr.  Wretlind,"  in  Hygeia,  1873,  March  No.,  pp.  142,  &c. 

- "  Allgemeine  Betrachtungeu  iiber  den  Wertb  der  Heilgymnastik,"  in  Wiener 
Medicinische  Presse,  1875,  Nos.  8,  9,  11,  13,  14,  15,  18,  21,  23. 

"The  lecture  has  been  reproduced  as  "  Neue  Heilmittel  fiir  Kranke  Nerven." 

*"■  Statistischer  Sanitatsbericlit...fur  1888,"  pp.  163,  &o. 

^  See  "  Om  Massage  vid  Blindtarmsinflammatiou,"  in  Tidskrift  i  Gymnastik, 
18S3,  pp.  687,  &c. 

"  Tidskrift  i  Gymnastik,  1887,  pp.  -594,  &c. 

'  "  Om  Nervtryckning,"  in  Noi-diskt  Mcdicinskt  Archiv,  1887,  vol.  xix..  No.  10. 

^  Pp.  279-284. 

"Pp.  237-240. 


148   ELEMENTS   OF  KELLGREN'S    MANUAL    TREATMENT 

Wide's  nerve  pressings  of  the  present  day  are  on  new  prin- 
ciples, and  differ  radically  from  the  nerve  pressings  of  the  Ling 
school  as  administered  formerly,  and  from  Kellgren's  nerve  treat- 
ment, as  can  readily  be  seen  from  the  following  extracts  from 
"  Handbook  of  Medical  and  Orthopaedic  Gymnastics,"  1903. 

"  The  gymnast  puts  both  his  hands  at  once  round  the 
extremity,  exercising  nerve-pressing  in  such  a  way  that  the 
somewhat  separated  and  bent  finger-tips  make  the  pressing  while 
a  slight  tremble-shaking  is  also  given.  As  the  gymnast  repeats 
this  pressing  several  times,  each  point  of  the  nerve  is  met  by  it, 
and  the  movement  will  thus  be  a  nerve  pressing,  but  still  more 
a  kind  of  muscle  kneading.  The  movement  is  very  agreeable 
to  the  patient,  but  unnecessarily  tiring  to  the  gymnast,  so  that 
in  most  cases  it  should  be  replaced  by  muscle  kneading." 

"Nerve-pressing  can  either  be  one  quickly  passing  as  when 
one  snaps  a  string,  which  is  often  repeated,  or  continual  for 
minutes  or  hours."  " 

Wide  also  makes  an  attempt  to  describe  nerve  frictions  on 
the  head,  but  says  : 

"  Nerve  frictions,  performed  on  other  parts  of  the  body,  are  as 
agreeable  as  head-nerve-friction,  and  certainly  possess  a  stimu- 
lating influence,  but  as  the  therapeutic  value  is  not  yet  satis- 
factorily explained,  I  shall  not  class  nerve-frictions  on  the 
extremities  and  trunk  as  special  forms  of  movement.  Ordinary 
nerve-massage  and  nerve-pressings  could  easily  replace  nerve- 
frictions."  '  (No  details  are  given  of  any  method  of  actually 
performing  nerve-massage.) 

Physiological  Effect!^  of  Nerve    Vibrations  and  Frictions. 

As  far  as  I  am  aware  no  experimental  work  has  been  done  in 
connection  with  the  above,  although  many  observers  have  studied 
the  effects  of  nerve  elongation  and  nerve  compressing.  The 
ensuing  account  of  the  physiological  effects  of  nerve  vibrations 
and  frictions  is  therefore  based  on  clinical  evidence  only.  The 
following  will  be  considered  in  detail : — 

(a)  Effects  produced  by  a  stationary  vibration  on  a  nerve  given 

'  P.  68 ;  see  also  "  Handbok  i  Medicinsk  och  Ortopedisk  Gymnastik,"  1902,  p.  57. 
-  P.  72  ;  see  also  "  Handbok  i  Medicinsk  och  Ortopedisk  Gymnastik,"  1902,  p.  62. 
■'P.  81. 


GYMNASTIC     MOVEMENTS  149 

with  medium  strength  from  the  wrist  and  finger-joints  continu- 
ously for  the  space  of  a  few  minutes. 

•  (b)  Effects  produced  by  stationary  friction  across  a  nerve  given 
with  a  medium  amount  of  strength  and  repeated  for  a  varying 
amoimt  of  time  from  a  few  seconds  up  to  a  minute. 

As  regards  the  other  groups  of  manipulations  it  is  very  difficult 
to  trace  clearly  their  different  efiects  as  these  vary  greatly  with 
different  patients,  according  to  their  degree  of  nervous  excitability, 
the  nature  of  their  malady,  &c. ;  each  set  of  manipulations  can  be 
modified  at  will  so  that  its  effects  coincide  with  those  of  another 
set  which  has  also  been  modified.  Thus  the  effects  produced  by 
the  above  two  methods  respectively,  which  are  at  their  extremes 
diametrically  opposite,  can  theoretically  be  united  by  an  infinite 
number  of  intermediate  stages. 

(a)    EFFECTS    OF    NERVE    VIBRATIONS. 

(1)  Removal  of  hyperexcitability  of  nerves. 

(2)  Diminution  of  any  pain  if  originally  present. 

(3)  Eemoval,  either  partial  or  complete,  of  the  signs  and 
symptoms  of  neuritis  or  neuralgia  (if  present),  and  removal  of 
lymph  and  venous  stasis  (if  present)  in  the  neighbourhood  of  the 
nerve,  without,  however,  causing  any  paralysis  of  sensation. 

(4)  Decrease  of  temperature  (sometimes). 

In  other  words  the  effects  are  sedative  and  analgsesic. 

(b)    EFFECTS    OF    NERVE    FRICTIONS. 

I. — Direct  Effects. 

(1)  Raising  of  the  nerve  functiunabilitij  {considerable). — In  con- 
sequence of  the  vibrations  set  up  by  the  friction  being  transmitted 
both  peripherally  and  distall}'  from  the  point  of  application,  the 
nerve  is  stimulated  not  merely  locally,  but  also  in  a  greater  part 
of  its  length. 

(2)  Sensory  effects. — The  moment  a  friction  is  applied  to  a 
healthy  sensory  nerve  a  sensation  of  pain  arises  in  it  at  the 
point  of  application,  also  shooting  down  its  ramifications ;  this, 
however,  disappears  in  a  very  few  seconds.  The  sensation  in 
question  is  very  similar  to  that  induced  by  electrical  stimulation. 
A  friction  of  the  same  intensity  on  an  irritated  or  painful  nerve 


I50  ELEMENTS   OF  KELLGREN'S   MANUAL    TREATMENT 

causes  a  temporary  increase  of  the  pain  already  present,  followed 
by  a  greater  diminution. 

(3)  Motor  Effects. — Frictions  on  a  motor  nerve  cause  increase 
in  the  tonicity  of  the  muscles  supplied  by  it.  Sometimes  actual 
contraction  occurs ;  this  is  generally  seen  to  advantage  in  spastic 
conditions.  In  the  case  of  cramp  or  spasm  of  muscles  a  friction 
on  the  nerve  supplying  them  will  cause  a  temporary  increase  in 
the  cramp  or  spasm,  usually  followed  by  a  greater  diminution. 

(4)  Secretory  effects. — Increase  in  the  amount  of  perspiration 
(either  general  or  local)  is  the  usual  result  of  nerve  frictions, 
although  in  certain  cases  {e.g.,  phthisis)  diminution  is  the 
consequence. 

(5)  Sijmpathetic-motor  and  vaso-motor  eff'ects. — These  can 
sometimes  be  obtained  directly,  but  are  usually  reflex.     Seep.  152. 

ll.—Beflex  Effects. 

The  subject  of  reflex  effects  inducible  by  nerve  friction  is  very 
extensive,  and  not  yet  fully  investigated ;  it  will  therefore,  be 
only  briefly  dealt  with. 

(1)  Muscles. — -Reflex  contraction  of  muscles  results  sometimes 
from  frictions  given  on  sensory  nerves,  whether  cutaneous  or 
deeper  lying.  Even  when  no  visible  contraction  takes  place 
there  is  still  a  tendency  towards  stimulation  of  the  muscles. 
Through  irritation  of  the  skin  the  metabolism  of  the  muscles, 
even  when  no  visible  contractions  appear,  is  most  markedly 
increased.  In  consequence  of  the  centripetal  sensory  stimula- 
tion the  muscles  are  urged  by  the  spinal  cord  to  increased 
metabolism;  there  is  greater  production  of  carbonic  acid  and 
warmth  (J.  Munk.') 

The  paths  travelled  by  the  reflex  during  the  foregoing 
phenomena  of  contraction  of  muscles  are  very  difierent.  The 
following  are  some  examples  taken  from  my  practice : — 

(rt)  Sensory  nerve  to  spine,  lateral  half  of  one  spinal  segment, 
motor  nerve  to  muscle.  Examples :  the  ordinary  skin  reflexes. 
In  one  case  of  hemiplegia  I  observed  that  a  friction  over  the 
radial  nerve  at  the  second  metacarpal  bone  caused  a  greater 
amount  of  involuntary  extension  of  the  wrist  and  fingers  than 
could  be  effected  voluntarily.     In  one  case  of  commencing  spastic 

'  "  Physiologie  des  Menschen  uud  der  Saugethiera,"  1897,  p.  426,  translated. 


GYMNASTIC  MOVEMENTS  151 

paraplegia  a  single  friction  on  the  long  saphenous  nerve  caused 
involuntary  coarse  twitchings  of  the  muscles  of  the  thigh  of  the 
same  leg ;  these  persisted  for  nearly  a  minute. 

(b)  Sensory  nerve  to  spine,  down  spinal  cord  of  the  same  side, 
motor  nerve  to  muscle.  Example  :  In  some  cases  of  hemiplegia 
a  friction  given  on  the  sensory  division  of  a  spinal  nerve  in  the 
cervical  region  of  the  affected  side  will  call  forth  twitchings  of 
the  muscles  of  the  leg  of  that  side.  This  may  also  be  seen,  only 
to  a  lesser  extent,  in  some  normal  persons. 

(c)  Sensory  nerve  to  spine,  across  the  spinal  cord  to  the 
corresponding  segment  on  the  opposite  side,  motor  nerve  to 
muscle.  I  have  only  been  able  to  observe  one  case  in  which 
this  took  place,  i.e.,  a  hemiplegia,  when  frictions  on  the  posterior 
divisions  of  the  cervical  nerves  on  the  unaffected  side  caused 
twitchings  in  the  (affected)  arm  of  the  opposite  side. 

(d)  Sensory  nerve  to  spine,  across  to  and  down  spinal  cord  of 
the  opposite  side,  motor  nerve  to  muscle.  E.xample  :  In  the  cases 
mentioned  under  (b)  frictions  on  the  corresponding  nerve  of  the 
healthy  side  sometimes  produce  the  same  phenomena,  only  to  a 
less  extent. 

(e)  Sensory  nerve  to  spine,  up  the  spinal  cord  of  the  same 
side,  motor  nerve  to  muscle.  Example  :  In  sclerosed  conditions 
of  the  crossed  pyramidal  tracts,  a  friction  given  on  the  internal 
plantar  nerve  with  a  moderate  amount  of  energy  will,  after  a 
latent  period  of  about  half  a  second's  duration,  cause  involuntary 
extension  of  the  toes  ;  if  given  more  energetically,  involuntary 
flexion  of  the  hip  occurs,  accompanied,  if  the  patient  be  in  half- 
lying  position,  by  passive  flexion  of  the  knee-joint.  (Arvid 
Kellgren  mentions  this  in  "  Technic  of  Ling's  System  of  Manual 
Treatment,"  1890,  p.  54.)  This  phenomenon,  which  I  will  term 
Kellgren's  plantar  sign,  no  doubt  results  through  the  same 
channel  as  Babinsky's  plantar  sign,  and  the  two  are  nearly 
always  found  together.  In  some  cases,  however,  where  there  is 
no  doubt  as  to  the  case  being  organic  and  not  functional, 
Kellgren's  sign  may  be  present,  but  not  Babinsky's. 

if)  Sensory  nerve  to  spine,  up  spinal  cord  of  same  side,  across 
to  spinal  cord  of  opposite  side,  motor  nerve  to  muscle.  Example  : 
In  the  case  referred  to  under  (e)  similar  involuntary  movements 
of  the  opposite  thigh  took  place  when  an  energetic  plantar  nerve 
friction  was  being  administered.  This  I  will  term  Kellgren's 
crossed  plantar  sign. 


152  ELEMENTS   OF   KELLGREN'S    MANUAL   TREATMENT 

(g)  Sensory  nerve  to  spine,  up  and  down  spinal  cord  of  same 
side,  across  to  and  up  and  down  spinal  cord  of  the  opposite  side, 
motor  nerve  to  muscle.  In  a  few  cases  of  very  excitable  ner- 
vous system,  an  energetic  friction  on  any  large  nerve-trunk  may 
cause  general  twitchings  of  the  whole  body. 

From  the  above  it  must  be  admitted  that  in  some  cases  it  is 
possible  through  nerve  frictions  to  stimulate  the  spinal  cord  to 
conduction  transversely  and  longitudinally  both  upwards  and 
downwards  ;  there  exists  consequently  a  direct  means  of  exciting 
the  sensory  columns,  the  internuncial  fibres  and  the  anterior 
horns  of  the  grey  matter  of  the  cord. 

(2)  Blood-vascular  system. — That  a  moderate  stimulation  of 
sensory  nerves  brings  about  cardio-acceleration  and  vaso-con- 
striction,  a  strong  one  cardio-retardation  and  vaso-dilatation,  is 
the  (generally  accepted)  result  of  electrical  stimulation,  although 
the  same  consequences  do  not  always  follow  from  mechanical 
irritation.^ 

Stimulation  of  sensory  nerves  of  the  skin  causes  vaso-con- 
striction  thereof  if  executed  lightl}',  but  the  reverse  if  executed 
energetically. 

Frictions  on  sympathetic  ganglia  or  nerves  or  on  the  cerebro- 
spinal nerves  in  physiological  communication  with  them  generally 
cause  contraction  of  the  blood-vessels  supplied  by  these  nerves, 
with  compensatory  dilatation  of  the  arteries  in  other  parts  of  the 
body  (see  p.  161).  The  latter  sometimes  gives  way  immediately 
afterwards  to  vaso-dilatation  which  is  again  followed  b}'  a  vaso- 
constriction, and  so  on ;  a  series  of  waves  is  set  up,  causing 
alternate  decrease  and  increase  in  the  size  of  the  arteries.  The 
final  result  may  be  either  a  return  to  the  original  condition,  a 
vaso-dilatation,  or  a  vaso-constriction,  depending  on  the  frequency 
and  intensity  with  which  the  frictions  are  administered,  and  on 
the  nature  of  the  malady  under  treatment. 

(3)  Sensation. — Various  reflex  sensations  can  be  induced ; 
some  of  these  will  be  referred  to  under  the  individual  nerves 
themselves.      The  sensation  induced  by  stimulation    of   sympa- 

'  See  Tigerstedt,  "  Lehrbuch  der  Phj-siologie  des  Kreislaufes,"  1893,  pp.  282,  &o. ; 
"  Lehrbuch  der  Physiologie  des  Menschen,"  1893,  p.  211.  Hill,  "  The  Mechanism 
of  the  Circulation  of  the  Blood,"  in  Schafer's  "Textbook  of  Physiology,"  vol.  ii., 
1900,  pp.  58,  &c.  Hunt,  quoted,  p.  156.  Kleen,  "  Uber  den  Einflusa  mechanischer 
Muskel  und  Hautreizung  auf  den  arteriellen  Blutdruck  beim  Kaninchen,"  in  Skmid. 
Archiv  f.  Phys.,  vol.  i.,  1889,  pp.  247,  Ac,  and  in  Nm-diskt  Medicinskt  Archiv, 
1888,  vol.  XX.,  No.  10. 


GYMNASTIC  MOVEMENTS  153 

thetic  nerves  or  ganglia  themselves  is  different  from  that  induced 
by  frictions  on  cerebro-spinal  nerves. 

(4)  Internal  organs. — Frictions  on  some  sensory  nerves  of  the 
skin  cause  an  increase  in  the  depth  of  respiration.  Frictions  on 
sympathethic  ganglia  or  nerves  or  on  the  cerebro-spinal  nerves  in 
physiological  communication  with  them  can,  probably  through 
the  same  segment  of  the  spinal  cord,  reflexly  stimulate  internal 
organs.  Actual  contraction  of  the  muscular  fibres  of  such  organs 
in  some  cases  manifests  itself. 

(5)  Glands. — Frictions  on  the  nerves  that  lie  over  glands  or 
that  are  in  physiological  communication  with  the  secreto-motor 
nerves  of  the  latter,  as  a  general  rule  cause  an  increase  in  the 
secretion  from  those  glands.  Sometimes,  however,  secreto- 
inhibitory  effects  are  obtained.' 

(6)  Pupils. — Reflex  dilatation  of  the  pupils  can  be  brought 
about  by  frictions  on  many  nerves,  both  cerebro-spinal  and 
sympathetic  {e.g.,  subtrapezial  plexus),  (generally,  a  series  of 
waves  of  alternating  contraction  and  dilatation  is  set  up,  these 
continuing  for  from  a  few  seconds  to  a  minute  or  even  longer. 
In  the  case  of  direct  manipulation  of  sympathetic  nerves,  there  is 
usually  a  latent  period  of  from  a  half  to  three  seconds'  duration. 

(7)  Pyretic  conditions. — Nerve  frictions  given  to  patients  with 
pyrexia  cause  decrease  in  the  temperature.  The  physiological 
explanation  of  this  is  not  obvious. 

(8)  Conditions  of  lowered  vitalitij  through  inflammation, 
trauma,  dx. — It  would  be  interesting  to  determine  whether  or 
not  frictions  over  the  nerves  leading  to  or  from  an  inflamed  or 
otherwise  pathologically  damaged  area  bring  about  an  increased 
tendency  to  repair,  by  improving  the  local  circulatory  reaction, 
which  as  is  known  is  due  in  great  part  to  the  central  reflex 
mechanism  (although  it  can  occur  when  the  vessels  are  cut  off 
from  the  nervous  system). 

Some  Other  Points  in  the  Physiological  Effects  of  Nerve  Frictions. 

Summation  of  inadequate  stimuli.- — In  many  cases  it  can  be 
demonstrated  that,  whereas  one  nerve  friction  is  insufficient  to 

'  This,  for  example,  has  been  showu  electrically  in  the  case  of  the  great  sciatic 
nerve  and  pancreatic  secretion.  See  Edkins  in  Schafer's  "  Textbook  of  Physiology,' 
vol.  i.,  1898,  p.  548. 

-  Cf.  Wiindt,  "  Untersuchungen  zur  Mekanik  der  Nerven,"  &o.,  1871,  vol.  i., 
p.  198. 


154  ELEMENTS   OF   KELLGREN'S    MANUAL    TREATMENT 

produce  a  desired  result,  this  result  may  j'et  be  obtained  through 
a  series  of  frictions  given,  as  far  as  it  is  possible  to  judge,  with 
the  same  intensity  and  at  the  same  spot. 

Summation  of  adequate  stimuli. — In  cases  of  hemiplegia  this 
can  frequently  be  demonstrated  as  follows  : — One  friction  on  the 
posterior  interosseous  nerve  of  the  affected  arm  produces  only 
slight  twitchings  in  the  paretic  extensors,  v?hereas  a  series  of 
frictions  in  rapid  succession,  given,  as  far  as  it  is  possible  to 
judge,  with  the  same  intensity  and  at  the  same  spot,  produces 
strong  contraction  in  them. 

Simultaneous  stimulation  of  a  nerve  trunk  at  two  points  of  its 
course  remote  from  one  another. — This  produces  an  extra  effect 
just  like  electrical  irritation  similarly  applied.  Example  :  In 
cases  of  atrophic  paralysis  of  a  leg,  &c.,  frictions  may  be 
administered  simultaneously  on  the  internal  plantar  and  great 
sciatic  nerves  of  the  same  side. 

Simultaneous  stimulation  of  several  nerve  trunks. — This  may 
be  resorted  to  in  order  to  obtain  a  great  additional  effect. 

Do  all  points  of  the  same  nerve  respond  equally  to  the  same 
stimulus';* — This  is  a  question  of  considerable  interest,  which, 
however,  I  cannot  definitely  answer.  Observers  on  sudden 
nerve  compression  by  means  of  tetanomotors  or  similar  apparatus 
are  at  variance  on  the  subject,  as  are  also  those  who  have  experi- 
mented with  electrical  stimuli.  (Hallsten  in  1875,'  Tigerstedt,- 
Hallsten  in  1881,'  Efron,^  Beck,''  Weiss,*  Munk  and  Schultz,' 
Eikhoff.*) 

'  "  Studier  i  Vafnadselemeateus  Physiologie.  Irritabiliteten  pi  olika  stallen  af 
samma  Nerv,"  in  Finska  Liikaresdllskapets  Handlingar,  1875,  pt.  2. 

-  "  Studien  iiber  mechauische  Nerveureizuug,"  1880. 

"' Zur  Kecntniss  der  mechanischeu  Reizung  derNerven,"  Archiv  fiir  Anat.  u. 
Phys.,  Physiol.  Abtheilung,  1881,  pp.  90-104. 

'  "  Beitrage  zur  Allgemeine  Nervenphysiologie,"  iu  Archiv  f.  d.  ges.  Phys.,  1885, 
vol.  xxxvi. ,  pp.  467-517. 

'"  Die  Erregbarkeit  verschiedene  Stelleu  desselben  Nerven,"  in  Arch.  f.  Anat.  u. 
Phys.,  Physiol.  Abtheil.,  1897,  pp.  415-425;  and  "  Zur  Untersuchungen  der  Erreg- 
barkeit der  Nerveu,"  in  Archiv  f.  d.  ges.  Physiol.,  1898,  vol.  Ixxii.,  pp.  352-359. 

"  "  Untersuchungen  iiber  die  Erregbarkeit  einen  Nerven  an  verschiedenen  SteUen 
seines  Verlaufes,"  in  Archiv  f.  d.  ges.  Phys.,  1898,  vol.  Ixxii.,  pp.  15-50;  "Neue 
Untersuchungen  iiber  die  Erregbarkeit  eines  Nerven  an  verschiedenen  Stellen  seines 
Verlaufes,"  ibid.,  1899,  vol.  Ixsv.,  pp.  265-302.  The  latter  contains  a  list  of  the 
literature  on  the  subject. 

'"Die  Reizbarkeit  des  Nerven  an  verschiedenen  Stellen  seines  Verlaufes," 
Archiv  f.  Anat.  uiid  Phys.,  Physiol.  Abtheil,  1898,  pp.  297-316. 

^  "  Uber  die  Erregbarkeit  der  motorischeu  Nerven  an  verschiedenen  Stellen  ihres 
Verlaufes,"  Arch.  f.  d.  ges.  Phys.,  1899,  vol.  Ixxvii.,  pp.  156-195. 


GYMNASTIC  MOVEMENTS  155 

Nerve  Frictioxs  and  Vibrations  v.  Nerve  Pressings. 

From  their  very  nature  there  can  be  no  possibility  of  frictions 
and  vibrations  causing  any  damage  to  the  nerves  or  paralysing 
them.  The  stronger  a  friction  is  administered  the  more  marked 
are  the  resulting  phenomena,  and  a  vibration  over  a  painful  nerve 
vi^ill,  even  if  it  entirely  removes  the  pain,  not  cause  any  paralysis 
of  ordinary  sensation  after  the  manipulation  is  over.  As  Grotch ' 
says,  "  The  methods  of  Uexkiill  (i.e.,  nerve  vibration  by  the 
'  nerve-shaker,'  see  p.  144),  or  modifications  of  these,  are  likely 
to  be  of  great  service  in  the  future,  as  their  employment  is 
not  accompanied  by  nerve  injury." 

I  have  in  some  cases  of  nervous  disease  tried  the  effect  of  both 
nerve  friction  and  nerve  pressing.  Although  sometimes  I  have 
found  a  muscular  response  to  the  former,  but  not  to  the  latter, 
I  have  never  found  the  reverse,  and  in  every  case  the  response 
has  been  greater  when  administering  a  friction  than  vi^hen 
applying  a  pressing. 

On  the  other  hand,  the  law  that  "  a  slight  pressure  stimulates 
a  nerve,  a  stronger  one  induces  pain,  and  a  still  stronger  one 
paralyses  it,"  has  been  known  to  Swedish  gymnasts  ever  since  the 
days  of  P.  H.  Ling.-  Even  a  pressure  of  medium  strength,  if 
kept  up  for  some  length  of  time,  will  cause  a  certain  amount  of 
paralysis,  and  cannot  do  otherwise  than  bring  about  venous  and 
lymphatic  stasis  in  the  nerve  itself,  and  the  tissues  immediately 
surrounding  it.  A  long-continued  pressure  repeated  daily  can 
only  result  in  permanent  damage. 

Differences  between  the  results  obtained  from  stimulating  a 
nerve  by  electricity  and  friction  respectively. — This  is  a  matter 
which  (as  far  as  I  know)  has  up  to  the  present  received  no 
experimental  attention.  Not  having  had  the  opportunity  of 
investigating  the  subject  myself,  I  shall  only  give  the  following 
examples  taken  from  clinical  observation  : — 

(1)  In  some  cases  of  paralysis  a  motor  effect  can  be  obtained 
from  a  friction,  but  not  from  electrical  stimulation. 

(2)  The  effects  of  a  friction  endure  for  some  time  after  the 
manipulation  is  over ;  the  effects  of  electric  irritation  do  not. 

'  Vide  Schiifer's  "  Textbook  oJ  Physiology,"  vol.  li.,  1900,  p.  468. 

^"  Gymnastikens  AUmanna  Gruuder,"  1834  (1840),  p.  71 ;  see  also  Hj.  Ling,  "De 
Piirsta  Begreppen  af  Rorelselaran,"  186G,  p.  106  ;  "  Forkortad  Ofversigt  af  Allmau 
Riirelselara,"  1880,  pp.  53,  &c. 


156  ELEMENTS    OF   KELLGREN'S    MANUAL   TREATMENT 

Some  of  the  chief  differences '  between  the  results  obtained 
respectively  from  other  forms  of  mechanical  excitation  and  from 
electric  stimulation  of  a  nerve  may  conveniently  be  referred 
to  here  : — 

(1)  Continued  compression  of  a  nerve  produces  paralytic 
symptoms  in  the  nerve  trunk  itself;  continued  electric  excitation 
does  not. 

(2)  Regarding  the  heart  and  blood-vessels,  Asp  -  found  that 
mechanical  stimulation  of  the  sciatic  plexus  of  a  dog  caused 
cardio-retardation,  an  electrical  one  cardio-acceleration.  Hunt  ^ 
found  that  kneading  of  the  muscles  of  a  leg  from  w^hich  the  skin 
had  been  removed  caused  a  fall  of  blood  pressure,  while  electrical 
stimulation  always  caused  a  rise  in  the  same. 

(3)  The  diminution  in  the  excitability  of  a  nerve  in  the 
kathelectrotonic  area  after  opening  a  constant  current  is  much 
less  evident  in  the  case  of  mechanical  than  in  tiiat  of  electrical 
stimulation  (Tigerstedt^). 

(4)  The  only  change  in  a  nerve  after  mechanical  stimulation  is 
a  slight  one  in  its  elasticity,  which,  moreover,  soon  passes  off 
(Tigerstedt^). 

(5)  Slow  rhythmical  vibrations  of  a  rate  considerably  less 
than  30  per  second  with  Uexkiill's  apparatus  (see  pp.  144,  155), 
induce  tetanus  in  muscle  as  well  as  secondary  contractions  ;  the 
latter,  however,  do  not  fuse.  This  result  differs  from  that 
obtained  from  electrical  stimulation  (Uexkiill ''). 

Detailed  Consideration  of  the  Individual  Nerves  and  Ganglia. 

The  sites  mentioned  in  connection  with  the  finding  of  indi- 
vidual nerves,  &c.,  have  special  reference  to  the  most  conveniently 

'  That  difierences  do  exist  was  known  to  the  Ling  school  at  least  as  long  ago 
as  1866.  See  Hj.  Ling,  "De  Fiirsta  Begreppen  af  Eiirelselaran,"  1866,  pp.  64  and 
96  ;  "  Porkortad  Ofversigt  af  Allmau  Rorelselara,"  1880,  p.  38. 

-  "  Beobaehtungen  iiber  Gef.Hssuerven,"  in  Berichte  der  Sticks.  Gesellschaft  der 
Wissenschaft,  Math-phys.  Classe,  18G7,  pp.  165,  &c. 

'■'  "  The  Pall  of  Blood  Pressure  resulting  from  the  Stimulation  of  Aiierent 
Nerves,"  in  Jotirnal  of  Physiology,  1895,  vol.  xviii.,  pp.  381-410. 

'"Die  durch  einen  constanten  Strom  in  den  Nerven  hervorgerufenen  Veran- 
derungen  der  Erregbarkeit  mittels  mechanischer  Reizung  untersucht,"  in  iVittlieil. 
an  der physiol.  Labor,  des  Car.  Mcd.-Chir.  Inst.,  1882,  pt.  1. 

"'  "  Studien  iiber  Meohanische  Nervenreizung,"  1880,  p.  48. 

"  "  Der  Neurokinet ;  ein  Beitrag  zur  Theorie  der  mechanischen  Nervenreizung," 
in  Zeitschrift  fi'rr  Biologie.,  vol.  xxxviii.,  pp.  291-299. 


GYMNASTIC   MOVEMENTS  157 

accessible  points  for  applying  the  frictions  and  vibrations.  In 
the  majority  of  cases  I  have  described  merely  frictions  on  nerves, 
but  the  sites  mentioned  are  the  same  for  giving  a  stationary 
vibration. 


(A)     Nerves  of  the  Head  and   Neck. 

(1)  Great  occipital  nerve  is  found  as  it  emerges  through  the 
trapezius  muscle  and  runs  upwards  and  outwards  m  the  scalp. 

There  must  be  some  very  intimate  connection  between  this 
nerve,  although  spinal  in  origin,  and  the  brain,  as  it  so  often 
happens  that  morbid  conditions  of  the  latter  are  associated  with 
great  tenderness  in  the  former.  In  some  cases  the  tenderness  of 
this  nerve  is  more  marked  than  that  of  many  of  the  other  nerves 
of  the  scalp,  which  are  cranial,  not  spinal,  in  origin. 

(2)  Small  occipital  nerve  and 

(3)  Posterior  auricular  nerve  are  found  as  they  run  over  the 
mastoid  process. 

(4)  Supraorbital  nerve  is  found  at  the  notch  or  foramen  of 
that  name,  and  in  its  course  in  the  scalp.  In  some  cases  there 
appears  to  be  a  physiological  continuity  between  this  nerve  and 
the  eyeball  itself,  and  the  same  may  be  said  of  some  of  the  other 
nerves  of  the  orbit  and  the  eyeball.  In  one  case  of  retinitis 
pigmentosa  and  one  case  of  optic  atrophy  after  retrobulbar 
hfemorrhage  that  I  treated,  there  was  greatly  impaired  sensation 
in  the  nerve  ;  in  two  cases  of  exophthalmic  goitre,  great  hyper- 
sesthesia.  In  one  patient  suffering  from  convergent  strabismus 
I  noticed  that  frictions  on  the  supraorbital  nerve  corrected  it  for 
a  second  or  two,  the  divergence  was  then  re-established,  and 
could  be  again  corrected.  In  the  course  of  about  six  weeks 
permanent  improvement  resulted.  I  may  add  that  the  patient 
was  under  treatment  for  an  old  poliomyelitis  anterior  acuta  in 
the  lumbar  region  of  the  cord. 

(5)  Supratrochlear  and  infra trochleccr  nerves  are  found  at  the 
inner  side  of  the  orbit. 

(6)  Nasal  nerve  is  found  as  it  passes  over  the  lower  edge  of 
the  nasal  bone.  Sensation  in  this  nerve  is  usually  diminished  in 
the  case  of  atrophic  conditions  of  the  nasal  mucous  membrane  ; 
the  reverse  obtains  in  the  case  of  hypertrophic  conditions.  In 
normal  persons  frictions  on  this  nerve  will  frequently  induce 
sneezing. 


158  ELEMENTS   OF   KELLGREN'S    MANUAL   TREATMENT 

(7)  Nerves  of  the  eyeball  itself  and  the  eyelids  are  found  as 
follows  :— 

(a)  The  patient's  eyelids  having  been  closed,  the  tip  of  the 
forefinger  is  placed  just  internal  to  the  vertical  diameter  of  the 
eye.  Light  frictions  applied  here  produce  a  peculiar  sensation 
in  the  ej'eball,  and  sonaetimes  also  in  the  frontal  region.  That 
the  seat  of  this  sensation  is  chiefly  in  the  eyeball  itself  is  shown 
by  the  fact  that  if  the  patient  be  asked  to  turn  his  eyes  to  one  or 
the  other  side  while  the  frictions  are  being  applied,  the  peculiar 
sensation  is  greatly  diminished,  the  loss  not  being  made  good 
until  the  cornea  again  lies  under  the  forefinger.  (6)  There  is 
a  certain  spot  situated  in  the  coronal  sutivre  over  the  site  of  the 
motor  area  for  movements  of  the  head  and  eyes.  Frictions  given 
on  it  often  cause  a  peculiar  sensation  as  of  pressure  in  the  eye- 
ball ;  unless  the  paint  be  found  exactly,  no  such  feeling  results. 
This  spot  does  not  lie  in  the  main  trunk  of  the  supraorbital 
nerve ;  moreover,  the  sensations  induced  by  friction  on  the 
former  do  not  resemble  those  evoked  by  friction's  on  the  latter, 
(c)  There  is  another  spot  on  the  scalp  where  a  similar  sensation 
can  be  obtained.  It  is  situated  in  or  near  the  line  of  the  occipito- 
parietal suture  at  about  the  level  of  the  occipital  protuberance. 

The  muscular  fibres  of  the  pupil  can  be  affected  reflexly 
through  many  nerves  (see  p.  153). 

(8)  Lachrymal  nerve. — A  branch  (most  probably  from  this 
nerve)  is  found  where  it  passes  round  the  outer  edge  of  the  orbit, 
just  at  the  outer  canthus. 

The  lachrymal  gland  can  be  fefiexly  affected  through  most  of 
the  sensory  nerves  of  the  face,  which  come  from  the  fifth  cranial 
nerve. 

(9)  Facial  nerve  is  found  as  it  comes  around  the  ascending 
ramus  of  the  lower  jaw ;  it  can,  as  a  general  rule,  be  quite  easily 
felt.  Filaments  can  also  be  felt  over  the  zygoma.  A  peculiar 
sensation  in  the  face,  and  sometimes  in  the  pharynx  and  ear, 
results  from  frictions  on  the  main  trunk. 

(10)  Sensory  branches  oj  the  fifth  nerve  that  lie  in  the 
masseter. — Frictions  on  these  will  often  in  a  few  minutes,  or  even 
seconds,  cure  neuralgic  toothache. 

(11)  Infraorbital  nerve  is  found  as  it  passes  out  of  the  foramen 
of  that  name. 

(12)  Mental  nerve  is  found  as  it  emerges  from  the  mental 
foramen  vertically  below  the  supraorbital  notch. 


GYMNASTIC    MOVEMENTS  159 

(18)  Lingual  nerve  is  found  high  up  internal  to  the  posterior 
part  of  the  horizontal  ramus  of  the  lower  jaw. 

The  submaxillary  ganglion  can  be  stimulated  by  a  friction 
from  behind  forwards  between  the  gland  and  the  lower  jaw,  at  a 
point  about  midway  between  the  angle  and  the  symphysis  menti. 

(14)  Hypoglossal  nerve  and 

(15)  Glosso-pharijngeal  nerve  are  found  below  and  internal  to 
the  horizontal  ramus  of  the  jaw. 

These  three  nerves  just  mentioned  can  all  be  conveniently 
stimulated  at  the  same  time  ;  in  order  to  effect  this  the  head  must 
first  be  passively  flexed  to  the  side  on  which  lie  the  nerves  it  is 
desired  to  manipulate 

(IG)  Superior  laryngeal  nerve  is  found  at  the  posterior  end  of 
the  upper  border  of  the  thyroid  cartilage.  Sensation  in  the 
larynx,  ear,  pharynx,  and  top  of  the  head,  sometimes  even  a  sense 
of  constriction  round  the  skull,  are  felt  in  many  subjects  on 
stimulating  this  nerve,  and  a  cough  is  frequently  induced. 

(17)  Inferior  {recurrent)  laryngeal  nerve  is  found  at  the  side  of 
the  trachea  low  down.  A  sense  of  constriction  in  the  larynx  is 
usually  felt  on  stimulating  this  nerve,  and  a  cough  often  results. 
In  addition  a  slight  feeling  of  vomiting  may  be  felt ;  this  is  most 
probably  a  reflex  rhrough  the  vagus. 

On  giving  a  friction  on  the  top  of  the  sternum  a  sense  of 
constriction  in  the  larynx  can  be  induced  similar  to  that  resulting 
from  friction  on  the  inferior  laryngeal  nerve.  The  peculiar 
sensation  in  question  is  in  some  persons  felt  in  the  bronchi 
as  well. 

(18)  Vagus  nerve  is  found  as  it  lies  under  cover  of  the  sterno- 
mastoid  between  the  internal  jugular  vein  and  the  internal 
and  common  carotid  arteries.  The  sterno-mastoid  having  been 
relaxed  by  bending  the  head  forwards  or  sideways,  the  finger  is 
passed  either  in  front  of  the  muscle  or  behind  it  (depending  on 
the  situation  in  the  neck  where  it  is  desired  to  stimulate),  and  the 
frictions  given  transversely  across  the  nerve. 

This  manipulation  will  in  some  persons  produce  cardio-retar- 
dation ' ;  in  others,  eructations  or  even  vomiting  will  result. 

(19)  Phrenic  nerve  is  found  low  down  in  the  neck  behind  the 
clavicular  insertion  of  the  sterno-mastoid.     Nerve  pressings  on  it 

'  Cf.  Tigerstedt,  "  Lehrbuch  der  Physiologie  des  Kreislaufes,"  1893,  pp.  237,  &c.  ; 
also  Waller,  "  Oa  the  Compression  of  the  Vagus  Nerve,  &c.,"  iu  Practitioner, 
December,  1870. 


j6o  elements    of   KELLGREN'S   MANUAL   TREATMENT 

were  formerly  used  by  the  Ling  ^  school  to  reheve  diaphragmatic 
spasm.  In  many  such  cases,  owing  to  the  difficulty  in  finding 
the  nerve,  it  would  be  better  to  resort  to  subcostal  shaking 
<p.  192),  shaking  over  the  bladder  (p.  16K),  and  subdiaphragmatic 
suction  (p.  217). 

(20)  Spinal  accessurt/  nerve  is  found  as  it  passes  downwards 
and  backwards  just  behind  the  sterno-mastoid  at  about  the 
middle  of  its  posterior  border.  Often,  however,  it  is  most  con- 
veniently stimulated  through  the  medium  of  the  subtrapezial 
plexus  (see  below). 

(21)  Siihtra-pezial  plexus  is  found  lying  in  the  substance  of  the 
trapezius  at  a  point  situated  in  a  line  drawn  directly  backwards 
from  the  middle  of  the  clavicle.  I  have  noticed  in  cases  of  disease 
of  the  female  pelvic  organs  where  chronic  shoulder-ache  was  an 
additional  distressing  symptom,  that  this  pain  could  be  localised 
to  the  subtrapezial  plexus  (sometimes  also  the  suprascapular 
nerve) ;  in  some  instances,  frictions  given  on  it  could  relieve  the 
pain.     For  effect  on  the  pupil,  see  p.  153. 

(22)  Brachial  plexus  in  the  neck. — The  primary  trunks  are 
found  by  passing  the  finger  deep  into  the  posterior  triangle  in 
front  of  the  trapezius.  Frictions  on  them  call  forth  a  kind  of 
-dull  boring  pain  which  is  unlike  the  sensation  resulting  from 
frictions  on  the  brachial  plexus  in  the  axilla. 

(23)  Cervical  spinal  nerves. — The  finding  of  some  of  the 
branches  of  these  nerves,  e.g.,  the  great  occipital,  small  occipital, 
&c.,  has  been  considered  already.  In  order  to  administer  frictions 
on  the  nerve  trunks  themselves,  one  hand  is  placed  on  the  back 
of  the  patient's  neck  so  that  the  tips  of  the  fingers  lie  on  one  side 
and  the  tip  of  the  thumb  on  the  other,  the  precise  point  of  appli- 
cation depending  upon  whether  the  posterior  or  the  anterior 
branches  of  the  nerves  are  to  be  stimulated.  The  former  are 
found  posteriorly  near  the  middle  line  as  they  emerge  through 
the  trapezius,  the  latter  ai-e  found  more  externally  and  anteriorly 
under  cover  of  and  in  front  of  that  muscle.  The  frictions  are 
given  from  before  backwards,  and  a  feeling  of  cold  or  warm 
shivers  down  the  spine  usually  results ;  in  some  subjects  the 
sensation  may  be  continued  so  as  to  be  felt  right  down  the 
limbs  to  the  very  toes. 

'  See  Branting's  address  to  tbe  graduates  of  the  G.C.I.,  on  April  1,  1844.  Also 
^juoted  by  Georgii,  "  Kinesith^rapie,"  1847,  p.  95.  See  also  Hj.  Ling,  "  De  Frirsta 
Begreppen  af  Eorelseliiran,"  1866,  pp.  92,  93,  141. 


GYMNASTIC    MOVEMENTS  i6l 

The  second  cervical  nerves  appear  to  contain  the  vaso-motor 
fibres  for  the  head ;  frictions  on  them  will  frequently  relieve 
headaches  that  are  a  consequence  of  hyperaemic  or  congested 
states  of  the  brain.  Such  frictions  are  particularly  useful  in  cases 
of  fever,  because  they  have  not  only  an  antipyretic  but  also 
stimulating  effect. 

Effect  of  cervical  nerve  frictions  on  the  spinal  cord. — It  is  very 
difficult  to  specify  the  exact  paths  along  which  the  stimulus 
travels,  but  most  probably  the  following  areas  in  the  cord  are 
affected  : — 

(«)   Sensorj'  columns. 

(b)  Internuncial  fibres. 

(c)  Anterior  horns  of  grey  matter. 

This  is  inferred  chiefly  from  clinical  study,  as  follows  : — 

When  the  sensory  columns  are  pathologically  affected  as  in 
cases  of  tabes  dorsalis,  no  feeling  of  cold  shivers  down  the  spine 
results  from  even  the  most  vigorous  frictions  on  the  cervical 
nerves,'  which  tends  to  show  that  normally  the  sensation  of  cold 
shivers  is  propagated  along  the  sensory  columns.  In  one  case  of 
disseminated  cerebro-spinal  sclerosis,  where  in  addition  to  the 
motor  symptoms  there  were  also  sensory  phenomena  such  as 
diminished  sensation,  "  cotton  wool "  under  the  feet,  &c.  (more 
marked  on  the  right  side),  the  sensation  of  cold  shivers  was  only 
felt  to  a  slight  degree  and  less  in  the  right  half  of  the  spine  than 
in  the  left  half.  In  one  case  of  gunshot  wound  of  the  spine 
at  the  level  of  the  fifth  dorsal  vertebra,  with  ensuing  complete 
motor  and  sensory  paralysis  below  the  site  of  the  lesion,  the 
bodies  of  the  vertebra  and  ribs,  and  with  them  the  sympathetic 
nerves,  being,  however,  uninjured,  the  cold  shivers  sensation  was 
felt  as  far  as  the  fifth  dorsal  segment  and  no  farther. 

In  some  cases  of  hemiplegia  cervical  nerve  frictions  will  cause 
involuntary  twitchings  or  even  coarse  movements  to  take  place  in 
the  affected  arm  or  leg.  [This  is  sometimes  seen  to  a  less 
extent  in  normal  people  (see  p.  151).]  Cold  shivers  down  the 
spine  are  usually  felt  by  such  patients. 

Effect  of  frictions  on  the  lower  cervical  nerves  on  the  sym- 
pathetic system.    The  following  phenomena  are  often  observed  : — 

(a)  Cutis  anserina  of  the  limbs. 

'  This  symptom  may  prove  of  value  in  the  difEerential  diagnosis  of  tabes  dor- 
.salis  and  peripheral  neuritis. 
11 


i62  ELEMENTS  OF   KELLGREN'S    MANUAL    TREATMENT 

{b)  Perspiration  over  the  whole  body,  speciallj'  in  nervous 
patients  and  in  fevers. 

(c)  An  effect  on  the  arteries  and  the  heart.  As  a  general  rule 
there  is  temporary  vaso-constriction,  which  is  followed  by  a 
certain  amount  of  vaso-dilatation  with  improved  and  slowed 
cardiac  action  ;  e.g.,  in  one  case  of  cardiac  dilatation,  with  a 
markedly  dicrotic  pulse  which  beat  1.50  per  minute,  the  above 
frictions  removed  the  dicrotism  and  reduced  the  pulse  rate  to 
130  per  minute,  the  cardiac  action  becoming  stronger-  These 
frictions  administered  to  a  patient  who  has  fainted  will  often 
result  in  recovery  immediately  after,  and  sometimes  even  during 
the  application  ;  the  pallor  of  the  face  and  lips  can  be  seen  rapidly 
to  give  way  to  the  normal  red  colour. 

(24)  First  cervical  sympathetic  ganglion  is  found  internal  to 
the  sterno-mastoid  high  up,  the  patient's  head  being  passively 
flexed  forwards  so  as  to  relax  those  muscles.  I  have  stimu- 
lated this  ganglion  in  some  cases  of  eye  and  middle  ear  affections. 

(25)  Second  cervical  sympathetic  ganglion  is  found  behind  the 
middle  of  the  sterno-mastoid,  the  patient's  head  being  as  described 
under  (24).  I  have  stimulated  this  ganglion  in  some  affections  of 
the  eye,  throat,  and  tongue. 

(26)  Third  cervical  sympathetic  ganglion  is  found  behind  the 
clavicular  insertion  of  the  sterno-mastoid  (which  must  be  relaxed 
as  before).  Frictions  are  given  on  it  with  the  finger  passed  in 
behind  the  muscle  specified.  In  some  cases  respiration  becomes 
deeper  and  fuller  as  a  result  of  the  manipulation. 

(B)     Nerves  of  the  Trunk. 

(1)  Intercostal  nerves  in  the  thora.v  lie  under  cover  of  the  ribs, 
which  must  be  elevated  in  order  to  better  expose  them.  The 
patient  is  consequently  placed  in  stretch  grasp  or  stretch  half 
lying  position,  and  the  frictions  are  then  given  from  before  back- 
wards near  the  lower  margin  of  the  upper  rib  of  each  intercostal 
space. 

The  normal  impulse  to  respiration  is  largely  derived  from 
sensory  impressions  from  the  cutaneous  nerves  which  pass  into 
the  spinal  cord  ;  and  frictions  on  the  intercostal  nerves,  presum- 
ably increasing  the  centripetal  stimulation,  in  many  cases  improve 
the  respiratory  function. 


GYMNASTIC  MOVEMENTS  163 

In  the  abdomen  reflex  contractions  of  the  muscles  of  its  wall 
are  frequently  found  as  a  result  of  irritative  or  inflamed  con- 
ditions of  organs  in  its  cavity.  The  same  state  of  matters  obtains 
with  the  thorax;  reflex  contractions  of  the  intercostal  muscles 
result  from  many  morbid  conditions  of  the  lungs,  bronchi,  and 
pleura.  Frictions  on  the  intercostal  nerves  of  the  affected  spaces 
appear  in  some  cases  to  act  beneficially  on  the  affected  internal 
part  (see  pneumonia  and  pleurisy). 

The  lateral  cutaneous  branches  of  the  intercostal  nerves  are 
found  emerging  a  little  in  front  of  the  raid-axillary  line,  their 
anterior  branches  ranning  forwards  and  their  posterior  ones 
backwards. 

The  anterior  cutaneous  branches  of  the  upper  six  intercostal 
nerves  are  found  as  they  emerge  near  the  outer  edge  of  the 
sternum. 

(2)  Descending  cervical  nerves  (from  the  superficial  part  of  the 
cervical  plexus)  are  found  as  they  pass  over  the  clavicle  down  to 
the  mammary  gland. 

(3)  Spinal  nerves  of  the  dorsal,  lumbar,  and  sacral  regions. 

(a)  Dorsal  spinal  nerves. — Their  anterior  branches  {i.e.  the 
intercostals)  have  already  been  referred  to  (p.  162).  The  posterior 
branches  are  found  as  they  emerge  through  the  erector  muscles 
of  the  spine  near  the  middle  line,  the  points  of  emergence  of  the 
lower  two  or  three  lying  more  externally  than  do  those  of  the 
others. 

(b)  Lumbar  spinal  nerves. — The  posterior  branches  are  found 
further  away  from  the  spine  than  the  corresponding  branches  of 
the  dorsal  nerves,  and  their  points  of  exit  diverge  from  above 
downwards,  so  that  the  lowest  ones  are  about  four  inches  from 
the  middle  hne  in  persons  of  ordinary  size. 

(c)  Sacral  spinal  nerves. — The  posterior  branches  are  found 
as  they  emerge  through  the  gluteus  maximus  and  erector  spinae, 
their  points  of  exit  converging  sHghtly  from  above  downwards. 

All  frictions  on  the  posterior  sensory  divisions  of  the  spinal 
nerves  should  be  given  as  much  as  possible  in  a  direction  at  right 
angles  to  their  course,  just  as  in  the  case  of  any  other  nerve, 
as  follows  : — 

Dorsal,  from  within  upwards  and  outwards. 

Lumbar,  from  within  outwards  and  slightly  upwards. 

Sacral,  from  withm  outwards. 


l64  ELEMENTS  OF   KELLGREN'S   MANUAL    TREATMENT 

Effect  of  frictions  on  the  posterior  divisions  of  the  dorsal, 
lumbar,  and  sacral  spinal  nerves. — Probably  the  same  parts  of  the 
spinal  cord  are  stimulated  as  in  the  case  of  cervical  nerve  frictions 
(see  p.  161),  though  the  resulting  phenomena  are  not  so  marked. 

Of  great  importance,  however,  are  the  effects  on  the  following 
ganglia : — 

(4)  Sympathetic  ganylla  of  the  thorax  and  ahdomen. — Each 
pair  of  these  is  in  anatomical  and  physiological  communication 
with  the  posterior  primary  divisions  of  the  corresponding  spinal 
nerves  by  means  of  the  rami  communicantes,  anterior  primary 
division  of  the  nerves,  spinal  cord,  and  recurrent  sensory  fibres. 

Henrik  Kellgren  in  the  early  days  of  his  practice  observed  that 
inflamed  or  irritative  conditions  of  various  internal  organs,  &c.,  are 
in  most  cases  accompanied  by  tenderness  in  various  spinal  nerves, 
which  is  specially  marked  over  the  sites  of  the  communicating 
cords  to  the  sympathetic  ganglia;  moreover,  it  has  been  estab- 
lished clinically  that  frictions  over  these  tender  areas  can  cause 
amelioration  in  the  morbid  conditions  of  the  parts  specified. 

The  following  symptoms  are  found  in  morbid  conditions 
respectively  of — 

{a)  Lungs  and  bronchi. — Tenderness  between  the  scapula;,  no 
doubt  due  to  the  fact  that  the  posterior  pulmonary  plexus  is 
largely  formed  from  the  second  to  fourth  thoracic  sympathetic 
ganglia.  I  have  never  failed  to  find  this  tenderness  with  acute 
bronchitis,  chronic  bronchitis,  and  phthisis  pulmonum.  In 
addition  there  is  often  tenderness  in  the  nerves  supplying  the 
intercostal  spaces  that  lie  over  any  affected  area  (see  intercostal 
nerves,  p.  163). 

(b)  Heart. — Tenderness  in  many  cases  when  frictions  are 
given  over  the  fourth  and  fifth  dorsal  nerves  of  the  left  side.' 

(c)  Liver  and  gall-bladder. — Tenderness  in  many  cases  when 
frictions  are  given  below  and  internal  to  the  inferior  angle  of  the 
right  scapula ;  the  area  corresponds  to  the  sixth  and  seventh 
dorsal  nerves. 

id)  Stomach. — Tenderness  in  many  cases  of  the  sixth,  seventh, 
and  eighth  dorsal  nerves  on  the  left  side ;  frictions  on  these 
nerves  may  cause  eructations.  In  morbid  conditions  of  the 
pylorus,  the  same  nerves  on  the  right  side  are  often  involved. 

'  Cf.  P.  H.  Liug,  "  Gymuastikens  Allmanna  Grunder,"  (183i),  1840,  p.  171. 


GYMNASTIC  MOVEMENTS  165 

(f)  Intestines. — Tenderness  of  the  sixth  to  eleventh  dorsal 
nerves ;  no  doubt  through  the  greater  and  lesser  splanchnic 
nerves.  The  same  nerves  are  tender  in  general  peritonitis  (see 
intercostal  nerves  in  the  abdomen,  p.  166). 

if)  Diaphragm. — Tenderness  on  giving  frictions  over  the  second 
(sometimes  also  the  first)  lumbar  nerves.  In  the  case  of  a  normal 
person  such  frictions  will  often  cause  him  to  "  catch  his  breath," 
although  no  pain  is  produced.  In  one  case  of  diaphragmatic 
pleurisy  that  I  treated  I  found  great  tenderness  over  the  last  two 
dorsal  and  the  first  two  lumbar  nerves. 

ig)  Spleen. — Tenderness  of  the  nintli  and  tenth  dorsal  nerves 
on  the  left  side. 

(h)  Kidneys. — Tenderness  of  the  tenth,  eleventh,  and  twelfth 
dorsal  nerves  ;  in  all  probability  through  the  least  (also  the  lesser) 
splanchnic  nerves,  which  end  in  the  renal  plexus. 

(i)  Genital  organs. — Tenderness  in  particular  of  these  spots  :  — 

(a)  Twelfth  dorsal  nerve. 

(/3)  Fifth  lumbar  nerve. 

(7)  Second  to  fourth  sacral  nerves. 

The  third  sacral  nerve  is  often  especially  painful  in  inflam- 
matory conditions  or  displacements  of  the  uterus. 

ij)  Rectum. — Tenderness  of  the  fourth  sacral  nerve. 

(k)  Bladder. — Tenderness  of  the  sacral  nerves,  more  par- 
ticularly the  first  and  third. 

It  will  be  noticed  that  the  affected  nerves  do  not  in  every 
case  correspond  to  the  tender  skin  areas  of  referred  pain  as 
determined  by  Head,'  and  in  many  cases  the  tenderness  can  only 
be  elicited  by  means  of  deep  pressure,  not  by  merely  touching 
the  skin. 

How  can  the  amelioration  that  takes  place  in  morbid  con- 
ditions of  these  various  organs  in  consequence  of  the  nerve 
frictions  be  explained  ?  It  is  possible  that  a  condition  of  matters 
obtains  analogous  to  that  in  the  case  of  muscles,  stimulation  of 
the  sensory  nerves  over  muscles  causing  increased  growth  and 
activity  (see  p.  150).  A  vaso-motor  element  may  also  be  present. 
The  whole  subject,  however,  demands  investigation,  not  merely 
from  a  therapeutic,  but  also  from  a  diagnostic  and  prognostic 
point  of  view. 

'See  "On  Disturbances  of  Sensation  with  Special  Reference  to  the  Paiu  of 
Visceral  Disease,"  in  Brain,  1893,  pts.  Ixi.  and  Ixii.,  pp.  1-132. 


i66  ELEMENTS   OF   KELLGREX'S   MANUAL    TREATMENT 

(5)  Intercostal  nerves  in  the  abdomen  are  found  by  placing 
the  patient  in  some  such  position  as  stretch  grasp  standing  or 
stretch  half  lying,  whereby  the  anterior  abdominal  muscles  are 
made  tense,  and  then  administering  frictions  over  each  nerve  as 
it  becomes  cutaneous  near  the  middle  line.  The  frictions  should 
take  place  from  without  inwards  in  a  line  from  above  downwards. 

There  is  a  close  connection  between  the  intercostal  nerves 
in  the  abdomen  and  viscera  of  that  cavity  through  the  medium 
of  the  lower  thoracic  ganglia  from  which  the  splanchnic  nerves 
are  derived  (see  p.  163). 

(6)  Ilio-hypogastric  nerve  and 

(7)  Ilio-ing'uinal  nerve  are  found  runnmg  forwards  near  the 
crest  of  the  ilium.  The  latter  can  also  be  found  in  the  inguinal 
canal,  where  frictions  made  transversely  across  it  will  greatly 
relieve  the  agonising,  sickening  pains  arising  from  contusions 
of  the  testicle. 

The  intimate  connection  existing  between  the  abdominal 
viscera  and  the  intercostal  nerves  (see  above)  seems  also  to  exist 
between  the  former  and  the  ilio-hypogastric  and  iho-inguinal 
nerves. 

(8)  Ganglion  impar  is  found,  when  the  patient  has  conve- 
niently been  placed  in  side  lying  or  forwards  lying  position,  by 
passing  the  last  phalanx  of  the  forefinger  on  to  the  anterior 
surface  of  the  tip  of  the  coccyx.  The  frictions  are  made  from 
above  downwards.  The  patient  in  many  cases  experiences  a 
kind  of  lightning  pain  through  the  abdomen,  with  a  desire  to 
defsecate  and  a  sensation  of  fulness  in  the  head  and  neck  ;  some- 
times his  face  can  even  be  seen  to  flush.  These  consequences 
show  that  the  sympathetic  nerves  of  the  abdomen  have  been 
stimulated  with  intestino-motor  and  vaso- constrictor  effect,  and 
compensatory  dilatation  of  the  vessels  in  the  more  distant  parts 
ensues  in  consequence. 

Some  patients,  during  the  administration  of  frictions  on  the 
ganglion  impar,  experience  a  "cold  shivers"  sensation,  similar 
to  that  induced  by  cervical  nerve  frictions,  proceeding  from  below 
upwards.  Others  have  told  me  that  they  felt  a  sharp  pain  at 
the  umbilicus. 

I  have  noticed  that  in  some  cases  of  habitual  constipation 
this  ganglion  has  given  no  sensation  at  all  on  stimulation,  and 
sensation  at  this  point  only  returned  gradually  as   the  consti- 


GYMNASTIC  MOVEMENTS  167 

pation  improved.  Thifs  absence  or  diminution  of  sensation  is 
also  found  in  patients  suffering  from  locomotor  ataxia  and 
paralysis  agitans. 

(9)  Coccygeal  nerve  is  found  when  frictions  are  given  trans- 
versely across  the  posterior  aspect  of  the  coccyx.  The  effects 
are  somewhat  similar  to  those  resulting  from  frictions  on  the 
ganglion  impar ;  the  desire  to  defecate  usually  results,  although 
the  vaso-motor  phenomena  are  absent. 

(10)  In  the  anterior  loall  of  the  rectum  there  is  often  great 
susceptibility  at  a  point  about  one  and  a  half  inches  from  the 
anus.  When  other  frictions  on  the  ganglion  impar,  sacral  nerves, 
&c.,  have  failed  for  the  time  being  in  bringing  on  a  rectal 
evacuation,  a  friction  from  above  downwards  over  this  spot  will 
often  succeed  in  so  doing. 

(11)  Renal  plexus  is  found  by  stimulating  the  tenth,  eleventh, 
and  twelfth  dorsal  nerves  as  described  on  p.  165,  also  by  placing 
the  patient  in  half  lying  position  and  proceeding  as  follows : 
The  assistant  places  his  fingers  on  the  patient's  abdomen  at  a 
point  about  three  inches  above  and  three  inches  external  to  the 
miibilicus  (in  persons  of  average  size)  ;  the  patient  then  breathes 
freely,  and  with  each  expiration  the  assistant  passes  his  fingers 
further  and  further  down  until  they  lie  deep  enough.  They  must 
not  be  thrust  in  suddenly,  as  that  would  bring  about  reflex 
contraction  of  the  abdominal  muscles,  which  would  at  once 
prevent  their  advancing.  (This  method  of  getting  deep  into  the 
abdomen  is  to  be  followed  out  in  all  cases  when  it  is  desired 
to  stimulate  structures  that  lie  far  back).  The  frictions  are 
given  from  without  inwards,  and  both  renal  plexus  and  kidney 
are  stimulated  simultaneously. 

Instead  of  the  fingers,  the  thumb  may  be  used ;  and  in  cases 
of  unusual  tendency  towards  reflex  contraction  of  the  abdominal 
muscles  the  patient  may  be  placed  in  crook  half  lying  position, 
when  those  muscles  are  more  effectively  relaxed  than  is  possible 
when  the  knees  are  kept  extended. 

(12)  Solar  j^lexus  is  found  when  the  fingers  are  pressed  in 
deeply  about  two  inches  below  the  xiphoid  cartilage.  The 
frictions  are  made  transversely  across  it,  and  stimulation  of  the 
abdominal  sympathetic  as  a  whole  is  often  the  result.  Similar 
effects  can,  however,  be  obtained  by : — 

(ft)  Making  frictions  on  the  umbilicus  itself,  in  which  case 


i6S  ELEMENTS  OF  KELLGREN'S    MANUAL    TREATMENT 

pain  is  felt  passing  up  to  the  sternum,  downwards  into  the  point 
of  the  penis  and  generally  speaking  radiating  in  all  directions  in 
the  abdomen. 

(6)  Shaking  the  pit  of  the  stomach  (see  p.  192). 
In  the  case  of  the  gunshot  wound  of  the  spine  referred  to  on 
p.  161,  sensation  was  normal  over  the  solar  plexus ;  nowhere  else 
in  the  abdomen,  however,  could  either  superficial  or  deep  frictions 
elicit  any  sensation  whatever. 

(13)  Syvipathetic  nerves  over  the  bladder  are  affected  by  vibra- 
tions or  shakings  in  an  upward  direction  just  over  the  symphysis 
pubis  about  an  inch  from  the  middle  line  (fig.  71).  This  often 
leads  to  an  immediate  desire  on  the  part  of  the  patient  for 
micturition ;  in  some  cases  a  rush  of  blood  to  the  head  also 
ensues. 

Henrik  Kellgren  has  found  that  vibrating  or  shaking  over  the 
bladder  has  the  extraordinary  effect  of  relieving  cough  and  render- 
ing respiration  freer.  I  have  had  abundant  opportunity  of 
observing  this  myself  in  diseases  of  the  respiratory  apparatus, 
more  especially  acute  and  chronic  bronchitis,  emphysema  and 
phthisis  of  the  lungs,  and  also  in  some  cases  of  stammering,  as 
follows : — 

Miss  S.  J.,  aged  16,  came  to  me  on  August  14,  1900,  with  the 
complaint  that  she  stammered.  This  defect  was  the  sequence  to 
a  fright  suffered  some  nine  years  earlier,  and  had  gradually 
developed  since  that  occasion.  Before  effecting  the  pronunciation 
of  a  word  and  then  again  before  each  following  word,  came  the 
syllable  "tut"  repeated  from  five  to  fifteen  times;  when  she 
became  excited  it  took  her  sometimes  as  much  as  a  minute  to 
utter  a  clear  articulation.  In  particular  I  found  rapid  spasmodic 
action  of  the  diaphragm  when  she  tried  to  speak,  and  a  great 
tenderness  over  the  bladder  when  I  gave  shakings  over  it ;  the 
abdominal  muscles  just  over  the  symphysis  were  hard  and  con- 
tracted. (The  urine  was  quite  normal).  I  treated  these  several 
parts  more  particularly  ;  and  at  the  end  of  six  weeks,  when  the 
patient  left,  the  muscular  contractions  were  gone,  the  bladder 
was  less  tender,  and  the  diaphragm  worked  better.  When  not 
excited,  the  patient's  speech  was  perfectly  normal.  I  also 
noticed  that  the  patient's  speech  varied  with  the  condition  of 
the  bladder;  the  better  the  latter  the  better  the  former,  and 
vice  vers&. 


GYMNASTIC  MOVEMENTS 


169 


I  have  observed  this  tenderness  over  the  bladder  and  con- 
traction of  the  abdominal  muscles  in  two  other  persons  who 
stammered,  but  as  I  saw  the  latter  only  once  in  consultation  and 
did  not  treat  them,  cannot  tell  whether  they  would  have  been 
cured  b}'  the  treatment  described  in  connection  with  the  first 
instance. 

There  must  be  some  very  intimate  connection  between  the 
sympathetic  nerves  over  the  bladder  and  those  of  respiration  ;  I 
am,  however,  unable  to  specify  the  anatomical  and  physiological 
channel. 

It  has  been  already  mentioned  that  stimulation  of  the  abdo- 
minal sympathetic  frequently  causes  vaso-dilatation  of  the  head. 


This  can  be  prevented  in  most  cases  by  administering  an 
energetic  vibration  on  the  coronal  suture ;  this  in  some  way 
induces  a  vaso-constrictor  effect  ^  (fig.  71). 

(14)  Inferior  hypogastric  plexus  is  situated  in  front  of  the 
promontory  of  the  sacrum.  The  assistant  passes  his  fingers  in 
deeply  (as  described  on  p.  167)  until  they  lie  over  the  promontory  ; 
the  frictions  are  given  transversely. 

(1-5)  Other  i^arts  of  the  ahdominal  sympathetic  are  found  deep 
down  near  the  middle  line,  and  can  be  stimulated  in  the  same 
way  as  the  above. 

'  See  Hartelius,  "  Larobok  i  SjukgjTnnastik,"  1870,  p.  91 ;  1883,  p.  92  ;  1892,  p.  91. 


I70  ELEMENTS   OF   KELLGREN'S    MAXUAL    TREATMENT 

(C)     Nerves  of  the  Upper  Extremity. 

(1)  Anterior  thoracic  nerves. — These  nerves,  which  supply  the 
pectoral  muscles,  are  found  either  hy  making  frictions  from  the 
front  through  these  muscles  or  by  passing  the  finger  round  the 
edge  of  the  muscles  in  an  inward  direction,  and  making  frictions 
on  their  posterior  surface. 

(2)  Suprascapular  nerve  is  found  as  it  emerges  from  the  supra- 
scapular foramen,  or  as  it  ramifies  in  the  substance  of  the  supra- 
and  mfraspinatus  muscles  (see  p.  160). 

(3)  Brachial  plexus  as  a  whole. — The  method  of  finding  and 
then  giving  frictions  on  this  plexus  above  the  clavicle  has  alread}' 
been  considered  (p.  1(30).  In  the  axilla  many  of  the  nerve  trunks 
are  to  be  felt  as  they  lie  around  the  artery  ;  they  can  be  stimulated 
by  means  of  frictions  across  them. 

(4)  Circumflex  nerve  is  found  either  through  its  lower  branch, 
which  is  met  posteriorly  as  it  emerges  from  the  quadrilateral 
space  and  ramifies  over  the  adjacent  skin  areas,  or  as  it  lies  under, 
in,  and  over  the  deltoid  muscle. 

(5)  Musculo-spiral  nerve  is  found  where  it  lies  between  the 
internal  and  external  heads  of  the  triceps,  and  lower  down  where 
it  lies  between  the  brachialis  anticus  and  the  supinator  longus. 

(6)  Median  nerve  is  found  : — 

(a)  In  the  axilla  as  it  lies  along  the  axillary  artery. 

(h)  In  the  upper  arm  as  it  runs  internal  to  the  biceps  muscle. 

(c)  At  the  elbow  as  it  lies  in  the  anticubital  fossa  in  the  middle 
line. 

{d)  In  the  forearm  as  it  courses  down  in  the  middle  line. 

(e)  In  the  hand  through  a  large  branch  which  lies  deeply 
along  the  inner  side  of  the  first  metacarpal  bone. 

(7)  Ulnar  nerve  is  found  : — 

(a)  In  the  axilla  as  it  lies  to  the  inner  side  of  the  axillary 
artery. 

(b)  In  the  upper  arm  as  it  lies  along  the  inner  border  of  the 
biceps. 

(c)  At  the  elbow  as  it  lies  in  the  groove  behind  the  internal 
condyle. 

{d)  In  the  forearm  as  it  runs  down  its  ulnar  aspect. 

(8)  Posterior  interosseous  nerve  is  best  found  as  it  winds  round 
the  radius  in  the  substance  of  the  supinator  brevis,  the  forearm 


GYMNASTIC  MOVEMENTS  171 

being  flexed  and  somewhat  pronated ;  it  can  also  be  stimulated  in 
its  course  at  the  back  of  the  forearm. 

(9)  Badial  nerve  is  found  where  it  lies  in  the  upper  part  of  the 
forearm,  along  the  inner  border  of  the  supinator  longus.  To 
render  the  nerve  accessible  the  forearm  must  be  somewhat  flexed 
in  order  to  relax  that  muscle ;  while  quickly  pronating  it  the 
frictions  are  administered  on  it  with  the  thumb. 

One  branch  may  also  be  found  as  it  lies  external  to  the  second 
metacarpal  on  the  dorsum  of  the  band  (see  also  p.  1-50). 

(D)     Nerves  of  the   Lower  Extremity. 

(1)  Superior  gluteal  nerve  is  found  where  it  runs  along  about 
two  inches  below  the  crest  of  the  ilium,  and  describing  the  same 
kind  of  curve  as  the  latter. 

(2)  Inferior  gluteal  nerve  is  found  where  it  runs  along  the 
inner  side  of  the  buttock. 

(3)  Great  sciatic  nerve  is  found  either  where  it  lies  between 
the  great  trochanter  and  the  tuberosity  of  the  ischium,  nearer 
to  the  latter,  or  in  its  course  down  the  middle  of  the  back  of 
the  thigh. 

(4)  Internal  popliteal  nerve. — In  order  to  find  this  nerve  the 
knee-joint  must  be  flexed  to  about  a  right  angle  in  order  to  relax 
the  popliteal  fascia.  Frictions  can  then  be  given  on  the  nerve 
as  it  runs  down  superficially  in  the  middle  of  the  popliteal  space. 

(•5)  External  popliteal  nerve  is  easily  found,  with  the  knee- 
joint  flexed  as  before,  behind  the  head  of  the  fibula  at  the  inner 
side  of  the  tendon  of  the  biceps. 

(6)  Anterior  tibial  nerve  is  found  where  it  runs  between  the 
tibia  and  the  fibula  to  the  outer  side  of  the  tibialis  anticus  ;  and 
lower  down  one  of  its  branches  can  be  followed  to  the  first 
interspace. 

(7)  Posterior  tibial  nerve  is  found  in  the  middle  line  at  the 
back  of  the  calf.  In  order  to  reach  it,  the  fingers  of  the  assistant 
and  the  superficial  calf  muscles  must  move  as  one  over  the  nerve. 
Lower  down  it  is  accessible  where  it  lies  behind  the  internal 
malleolus. 

(8)  Internal  plantar  nerve  is  found  where  it  lies  to  the  outer 
side  of  the  abductor  hallucis.  Frictions  may  also  be  adminis- 
tered on  the  large  branch  that  goes  to  supply  the  first  interspace. 


172  ELEMENTS    OF   KELLGREN'S   MANUAL    TREATMENT 

The  effects  of  such   a  friction  in   spastic  conditions  have  been 
described  on  p.  151. 

(9)  External  plantar  nerve  is  found  where  it  runs  obliquely 
across  the  foot  from  within  outwards.  In  spastic  conditions  the 
effects  of  frictions  on  it  are  the  same  as  in  the  case  of  the  internal 
plantar  nerve,  although  not  so  strongly  marked. 

(10)  Musculo-cutaneous  nerve  is  found  high  up  as  it  lies 
between  the  peronei  muscles,  and  lower  down  as  it  lies  cuta- 
neously. 

(11)  Anterior  crural  nerve  is  found  where  it  lies  between  the 
psoas  and  iliacus  at  Poupart's  ligament,  and  also  where  it  divides 
into  its  various  branches  in  the  upper  part  of  the  thigh. 

(12)  Long  saphenous  nerve  being  cutaneous  in  the  greater  part 
of  its  extent  is  easily  found  along  the  inner  side  of  the  leg. 
There  seems  in  some  cases  to  be  a  physiological  connection 
between  this  nerve  and  the  ovary  of  the  same  side. 

(13)  External  cutaneous  nerve  (from  the  lumbar  plexus)  is 
found  where  it  becomes  cutaneous  below  the  anterior  superior 
spine  in  the  upper  third  of  the  thigh.  This  nerve  is  often  tender 
in  affections  of  the  kidney. 

(14)  Obturator  nerve  is  found  as  it  emerges  from  the  thyroid 
foramen,  the  thigh  being  somewhat  flexed,  abducted  and  ex- 
ternally rotated,  and  in  its  course  along  the  adductor  muscles. 

(15)  Short  saphenous  nerve  being  cutaneous  in  the  greater 
part  of  its  length,  is  easily  found  on  the  postero-external  aspect 
of  the  calf. 

(16)  Sensory  nerves  of  the  foot,  i.e.,  long  saphenous,  short 
saphenous,  musculo-cutaneous,  anterior  tibial,  internal  plantar, 
external  plantar  and  plantar  cutaneous  from  the  posterior  tibial 
are  conveniently  found  and  stimulated  in  groups  by  administering 
frictions  with  the  backs  of  the  nails  over  the  skin  of  the  dorsum 
and  sole  of  the  foot. 


Exercises  comprising  the  Treatment  of  Nerves  in   Regions. 

All  the  following  sets  of  running  frictions  (or  running  vibra- 
tions) are  generally  given  three  times  in  succession,  and  should 
be  executed  with  all  possible  evenness  and  continuity.  The 
number  of  applications  may,  however,  be  increased,  if  the  indica- 


GYMNASTIC  MOVEMENTS  173 

tions  seem  in  favour  of  such  a  proceeding,  especially  in  cases  of 
nerve  manipulations  of  the  head. 

(1)  Head  and   Face. 

The  patient  assumes  the  sitting  position.  The  assistant  may 
give  running  frictions  or  vibrations  as  follows  : — - 

(1)  In  the  lines  of  the  superior  longitudinal  and  great  lateral 
sinuses.  The  cutaneous  nerves  of  the  part  are  stimulated,  and 
cold  shivers  dovv^n  the  spine  are  often  felt,  the  sensation  being 
similar  to  that  caused  by  cervical  nerve  frictions,  although  less 
marked.' 

(2)  Around  the  side  of  the  skull.  The  assistant's  fingers  begin 
in  the  middle  line  anteriorly  between  the  tuberosities  of  the 
frontal  bone,  and  pass  horizontally  backwards  until  the  great 
occipital  nerve  is  reached,  along  which  they  travel  downwards 
and  inwards  (fig.  88,  p.  222).  The  chief  nerves  stimulated  are 
— supra-orbital,  temporo-facial,  temporal  branches  of  the  facial, 
auriculo-temporal,  small  and  great  occipital.  As  in  (1)  above, 
the  sensations  of  cold  shivers  may  also  be  felt. 

(3)  On  the  facial  or  fifth  nerves  or  other  individual  nerves  if 
they  call  for  special  attention  (see  head  exercise,  p.  220). 

(2)  Upper   Extremity. 
Yard  Sitting  Arm  Running  Nerve  Frictions,  PP. 

The  assistant  having  brought  the  arm  which  is  to  be  stimu- 
lated into  yard  position,  supports  it  in  that  position  with  one 
hand,  using  the  fingers  of  his  other  hand  to  give  the  frictions 
or  vibrations.  He  begins  in  the  axilla  over  the  brachial  plexus 
and  proceeds  downwards  along  the  inner  edge  of  the  biceps, 
thus  reaching  the  median  and  ulnar  nerves,  and  then  follows 
the  latter  nerve  round  the  internal  condyle  down  the  front  of 
the  forearm,  fourth  metacarpal  and  the  third  finger  right  to  its 
very  tip,  where  the  median  and  radial  nerves  are  found  as  well. 
He  then  returns  via  the  back  of  the  third  finger  and  fourth 
metacarpal  (ulnar  and  radial   nerves),  the  back  of  the  forearm 

'  Georgii  and  Branting  ascribed  to  this  manipulation  the  effect  of  constriction  of 
the  vessels  of  the  scalp.  See  Branting's  address  to  the  graduates  of  the  G.  C.  I.  on 
April  1,  1842;  also  quoted  by  Georgii  "  Kinesitherapie,"  1847,  pp.  84  aud  85  ;  and 
'•  Kinetic  Jottings,"  1880,  p.  192. 


174  ELEMENTS   OF  KELLGREN'S   MANUAL    TREATMENT 

(posterior  interosseous  nerve)  on  to  the  niuscalo-spiral  nerve,  and 
along  the  latter  to  near  the  shoulder.  Thereupon  he  passes  along 
the  posterior  branch  of  the  circumflex  nerve  to  the  suprascapular 
nerve,  across  the  suprascapular  fossa  and  then  downwards  between 
the  shoulder  blade  and  spinal  column  over  the  upper  dorsal 
nerves.  The  cutaneous  nerves  in  the  course  of  the  manipulation 
are  stimulated  in  addition  to  the  deeper  lying  trunks. 

(3)  Lower  Extremity. 
Half  Lying  Double  Leg  Running  Nerve  Frictions,  PP. 

Both  legs  are  treated  simultaneously,  the  assistant  using  one 
hand  for  each  limb.  He  begins  over  the  great  sciatic  nerve  high 
up,  and  follows  it  downwards  to  its  termination,  going  along  the 
internal  popliteal,  posterior  tibial,  and  internal  plantar  to  the 
interval  between  the  first  and  second  metatarsals.  He  then 
passes  on  to  the  dorsum  of  the  foot  and  travels  up  to  the  pelvis 
along  the  anterior  tibial  and  external  cutaneous  nerves.  On 
repeating  the  frictions,  he  may  return  via  the  anterior  tibial,  long 
saphenous,  internal  cutaneous  and  obturator  nerves. 

The  cutaneous  nerves  in  the  path  of  the  manipulation  are 
stimulated  in  addition  to  the  deeper  lying  trunks. 

Side  Lying  Leg  Running  Nerve  Frictions,  PP. 

The  assistant  only  treats  one  leg  at  a  time  (the  uppermost 
one),  his  two  hands  travelling  simultaneously  and  at  the  same 
rate ;  one  of  them  proceeds  along  the  great  sciatic  nerve  down 
to  the  end  of  the  internal  plantar  nerve  (as  in  the  last  exercise), 
the  other  along  the  external  cutaneous  and  anterior  tibial  nerves, 
finishing  up  at  the  termination  of  the  latter  in  the  space  between 
the  first  and  second  metatarsals.  Then  the  frictions  may  be 
recommenced  from  above,  or  the  hand  last  mentioned  may  first 
travel  back  in  the  reverse  direction. 

The  cutaneous  nerves  lying  in  the  path  of  the  manipulation 
are  stimulated  in  addition  to  the  deeper  lying  trunks. 

The  cutaneous  nerves  of  the  foot  have  been  enumerated  on 
p.  172,  they  may  call  for  separate  treatment,  but  most  of  them 
are  stimulated  by  means  of  the  above  exercise. 


GYMNASTIC  MOVEMENTS  175 

(4)    Cerebro-spinal  System   as  a  Whole. 
Forwards  Lying  Head  to  Foot  Running  Nerve  Frictions,  PP. 

The  assistant  gives  the  same  frictions  simultaneously  on  both 
sides,  so  the  method  on  only  one  side  will  be  described.  His 
fingers  begin  in  the  middle  line  internal  to  the  tuberosities  of 
the  frontal  bone,  and  pass  on  round  the  sides  of  the  skull  and 
down  the  great  occipital  nerve  (see  (2)  p.  173)  to  the  posterior 
sensory  branches  of  the  cervical  nerves.  They  then  pass  over 
the  subtrapezial  plexus  and  suprascapular  fossa  down  the  front 
of  the  deltoid  muscle  (anterior  division  of  the  circumflex  nerve), 
along  the  outer  edge  of  the  biceps  (cutaneous  nerves)  and  back 
again  over  the  musculo-spiral,  posterior  division  of  the  circumflex 
and  suprascapular  nerves,  and  from  there  to  the  first  dorsal 
nerve.  After  this  they  pass  down  the  back  near  the  middle  line, 
giving  frictions  over  the  sensory  divisions  of  each  spinal  nerve, 
affecting  in  turn  the  dorsal,  lumbar  and  upper  sacral.  (The 
method  of  doing  the  latter  has  been  described  on  p.  163.) 
Having  reached  the  third  sacral  nerve,  they  pass  outwards  on  to 
the  great  sciatic  nerve  and  follow  it  down  the  leg,  successively 
giving  frictions  on  the  internal  popliteal,  posterior  tibial  and 
internal  plantar  nerves,  and  finishing  up  in  the  interval  between 
the  first  and  second  toes  in  the  sole  (fig.  72).  The  cutaneous 
nerves  in  the  path  of  the  manipulation  are  stimulated  in  addition 
to  the  deeper  lying  trunks. 

The  effects  resulting  from  this  exercise  may  be  greatly 
intensified  by  causing  the  frictions  to  be  administered  simul- 
taneously by  three  assistants.  The  first  assistant  will  begin  as 
described  above ;  when  he  is  about  half  way,  the  second  will 
follow  suit ;  and  the  third  will  begin  when  the  second  is  about 
half  way  (by  which  time  the  first  is  just  finishing  at  the  internal 
plantar  nerve).  As  soon  as  the  third  is  half  way  the  first  re- 
commences, and  so  on,  each  assistant  administering  the  frictions 
three  times. 

Stretch  Side  Lying  Hand  to  Foot  Running  Nerve  Frictions,  PP. 

These  frictions  are  usually  administered  first  on  one  side  of 
the  body  and  then,  the  patient  turning  over,  on  the  other.     In 


176  ELEMENTS   OF   KELLGREN'S    MANUAL    TREATMENT 

some   cases   of    unilateral   conditions,    such   as    heniianaesthesia, 
hemiplegia,  &c.,  only  the  affected  side  is  treated  ;  but  even  in 


such  conditions  it  is  often  of  advantage  to  include  the  healthy 
side  as  well,  because  the  patient  having  learnt  how  the  frictions 


GYMNASTIC  MOVEMENTS  177 

feel  on  the  healthy  side  is  rendered  more  capable  of  recognising 
them  on  the  affected  side ;  besides  which,  the  cerebro-spinal 
system  is  stimulated  bilaterally,  raising  the  nervous  tone  as  a 
whole. 

The  assistant  executes  the  frictions  simultaneously  with  both 
hands,  which  travel  at  the  same  rate.  The  paths  travelled  by 
his  hands  are,  however,  different,  and  must  be  described 
separately. 

One  hand  begins  anteriorly  over  the  third  finger  of  the 
patient's  hand,  and  travels  along  the  ulnar  nerve  as  it  lies  in 
in  the  hand,  forearm,  along  the  inner  border  of  the  biceps,  and 
in  the  axilla.  The  hand  having  reached  the  ribs,  a  friction  is 
executed  over  each  intercostal  nerve  in  the  anterior  axillary  line, 
thus  stimulating  also  the  anterior  branch  of  each  lateral 
cutaneous  nerve.  It  then  passes  along  the  side  of  the  abdomen 
in  the  same  line,  reaching  the  last  dorsal,  ilio-hypogastric, 
ilio-inguinal  nerves,  &c.,  from  which  it  travels  down  the  antero- 
external  aspect  of  the  leg,  executing  frictions  on  the  external 
cutaneous  and  anterior  tibial  nerves,  and  finally  passes  along 
the  dorsum  of  the  foot  in  the  path  of  the  nerve  last  mentioned 
until  the  interval  between  the  first  and  second  metatarsals 
is  reached. 

The  assistant's  other  hand  begins  posteriorly  over  the 
patient's  third  finger  (ulnar  and  radial  nerves),  and  having 
reached  the  forearm  travels  along  the  posterior  interosseous, 
musculo-spiral  and  circumflex  nerves  on  to  the  ribs  ;  a  friction  is 
executed  on  each  intercostal  nerve  in  the  posterior  axillary  line, 
the  posterior  branch  of  each  lateral  cutaneous  nerve  being  also 
stimulated.  It  then  travels  along  the  side  of  the  abdomen  in 
the  same  line,  and  passing  on  to  the  leg,  executes  frictions 
on  the  sensory  nerves  of  the  gluteal  region,  great  sciatic,  internal 
popliteal,  posterior  tibial  and  internal  plantar  nerves,  finishing 
similarly  to  the  other  hand,  bi;t  on  the  corresponding  plantar 
aspect  (fig.  73).  The  cutaneous  nerves  in  the  path  of  the 
manipulation  are  stimulated  in  addition  to  the  deeper  lying 
trunks. 

Stretch  Half  Lying  Hand  to  Foot  Running  NerYe  Frictions,  PP 

The   same   manipulations   being  executed  simultaneously  on 
both   sides   of    the   body,   it  is   only  necessary   to   describe   the 
12 


178  ELEMENTS   OF   KELLGREN'S   MANUAL    TREATMENT 

path   traversed    by   one    of    the    assistant's   hands.      Beginning 
over  the  patient's  third   finger,  a  series  of  running  frictions  is 


administered  along  it  and   the  fourth  metacarpal,  forearm  and 
upper  arm,  with  the  assistant's  thumb  on  the  anterior  aspect 


GYMNASTIC  MOVEMENTS  r/g 

and  bis  fingers  on  the  posterior,  in  turn  stimulating  anteriorly 
the  ulnar  and  median  nerves,  and  posteriorly,  the  radial,  ulnar, 
posterior  interosseous,  musculo-spiral  and  circumflex  nerves. 
The  thumb  and  fingers  then  meet  and  execute  frictions  on  the 
intercostal  nerves  in  the  mid-axillary  line,  thereby  also  stimulating 
their  lateral  cutaneous  branches  around  the  side  of  the  abdomen 
in  the  same  line  (see  above  p.  177),  the  external  cutaneous  nerve 
in  the  thigh,  and  the  anterior  tibial  nerve  as  far  as  the  ankle-joint. 
The  thumb  follows  the  last  mentioned  nerve  to  its  termination 
between  the  first  and  second  metatarsals,  while  the  fingers  pass 
on  to  the  sole  and  follow  the  internal  plantar  nerve  to  its 
termination  on  the  corresponding  plantar  aspect  (fig.  74).  The 
cutaneous  nerves  in  the  path  of  the  manipulation  are  stimulated 
in  addition  to  the  deeper  lying  trunks. 

In  any  of  the  above  exercises  on  the  cerebro-spinal  system  as 
a  whole,  frictions  may  be  administered  along  each  intercostal 
nerve  for  the  greater  part  of  its  length.  This  is  effected  more 
easily  in  the  case  of  the  last  two  exercises  than  in  that  of  the 
first  one  mentioned,  because  in  the  initial  position  the  patient's 
arms  are  stretched  up,  and  thus  the  ribs  are  elevated  and  the 
nerves  rendered  more  accessible. 

An  additional  effect  can  be  obtained  from  the  last  two  exercises 
by  applying  traction  at  the  hands  and  feet  while  the  frictions 
take  place.  Three  assistants  are  required  to  carry  out  this  com- 
bination, one  to  execute  the  running  nerve  frictions  while  the 
other  two  apply  the  traction. 

For  the  sake  of  brevity  I  shall  omit  the  qualifying  words 
"hand  to  foot,"  "head  to  foot,"  and  simply  term  the  manipula- 
tions "  running  nerve  frictions";  thus  "forwards  lying  running 
nerve  frictions,  PP.,"  &c. 

Effects  of  all  the  above  running  nerve  frictions  : — ■ 

(1)  Stimulation  of  the  cerebro-spinal  system  as  a  whole. 

(2)  Stimulation  of  the  sympathetic  system  as  a  whole,  with 
(usually)  vaso-constrictor  effect  followed  by  vaso-dilatation  and 
then  a  return  to  the  normal  (see  p.  1-52). 

(3)  Stimulation  of  the  motor  nerves  in  the  path  of  the  ma- 
nipulation. 

(4)     Stimulation  of  the  sensory  nerves  (deep  lying  as  well  as 
cutaneous)  in  the  path  of  the  manipulation. 


i8o    ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

Stretch  Half  Lying  Double  Hand  and  Foot  Nerve  Frictions,  PP. 

One  assistant  finds  both  median  nerves  where  they  lie  internal 
to  the  first  metacarpal  bones ;  the  other  finds  both  internal 
plantar  nerves  vphere  they  lie  in  the  soles  of  the  feet ;  they  then 
execute  six  to  ten  frictions  simultaneously  on  these  nerves.  This 
is  repeated  three  times.  Many  patients  during  this  process  feel  a 
kind  of  lightning  sensation  throughout  the  body. 

In  patients  with  very  dulled  nervous  systems,  or  in  other  cases 
where  very  powerful  stimulation  is  required,  frictions  may  be 
executed  over  several  nerves  simultaneously,  such  as  cervical  on 
both  sides,  both  median  in  the  hands,  both  internal  plantar  in 
the  feet,  both  great  sciatic  in  the  buttocks,  &c. 

(5)  Cutaneous  Nerves  of  Congested  or  CEdematous  Areas. 

Running  vibrations  or  frictions  are  frequently  prescribed  for 
such  nerves.  The  part  affected  should  be  placed  so  that  the 
venous  and  lymph  return  can  proceed  in  the  direction  of  gravity  ; 
thus  if  the  condition  be  present  in  a  leg,  the  patient  is  placed 
on  his  back  in  lying  or  half  lying  position,  and  that  leg  flexed 
to  an  angle  of  30°  or  so  with  the  horizontal,  and  supported  in  that 
position.  The  vibrations  or  frictions  are  then  executed  in  a  cen- 
tripetal direction. 

If  done  lightly,  the  effect  of  such  manipulations  is  vaso- 
constriction of  the  vessels  of  the  limb  (see  p.  1.52). 

Nerve  frictions  and  vibrations  have  now  been  considered  in 
some  detail.  I  have  only  to  restate  that  this  method  of  treatment 
has  succeeded  in  eliciting  a  great  many  new  physiological  nerve 
continuities  for  which  no  anatomical  explanations  at  present 
exist.  A  large  field  awaits  the  investigator,  and  doubtless 
scientific  research  will,  in  course  of  time,  reveal  the  exact 
nature  of  these  nerve  continuities  and  accurately  map  them  out 
on  a  sound  anatomical  basis. 

II. — A^IBR.\TIONS    AND    SHAKINGS    ON    OtHER    STRUCTURES. 

History  and  devdopment. — In  the  1840  edition'  of  P.  H. 
Ling's    "  Gymnaatikens  AUmiinna  Grander"    very  little  is  said 

'  See  p.  155  of  that  work. 


GYMNASTIC   MOVEMENTS  i8i 

about  shaking  or  vibration ;  in  the  1866  edition '  shaking 
is  described,  but  not  vibration.  In  Branting's  gymnastic  pre- 
scriptions of  1828-1839"  many  shaking  movements  are  mentioned, 
and  additional  ones  are  described  by  him  in  his  addresses  to 
the  graduates  of  the  G.  C.  I.  in  1842,  1843,  1846,  1848. 
Rothstein.Mn  1847,  distinguishes  betv?een  "  Erschiitterung  "  and 
"Zitterung";  Neumann/  however,  almost  exclusively  uses  the 
former  term.  Georgii^in  1847,  speaks  of  "tremblements."  Roth," 
in  1856,  refers  only  to  vibration ;  Hartelius,'  in  his  handbook, 
speaks  only  of  shaking,  not  of  vibration. 

A  list  of  the  shaking  and  vibrating  movements  which  were 
in  common  use  under  Branting  can  be  found  in  the  writings  of 
Neumann,*  Eoth,*  Branting,'"  Georgii,"  and  Hartelius.^-  Some- 
times shakings  were  administered  simultaneously  with  active 
exercises,  such  as  lower  jaw  shaking  with  alternate  closing  and 
opening  of  the  mouth,*'  sitting  head  shaking  with  passive  turning/* 
and  sitting  nose  root  shaking  with  trunk  extension  (the  patient 
having  first  flexed  his  trunk  on  the  hip-joints).^' 

When  Henrik  Kellgren  began  to  deal  with  cases  of  acute 
specific  infectious  disease,  he  continually  found  it  necessary  to 
resort  to  manipulations  of  shaking  and  vibration ;  in  consequence 
he  was  impelled  to  develop  and  improve  these  methods  of  treat- 
ment.    No  detailed  or  systematic  account  of  them  has  yet  been 


'  See  p.  581  of  that  work. 

- "  Efterlemuade  Skrifter,"  1882,  part  2,  p.  1,  &c.,  and  gymnastic  prescriptions 
at  end  of  book. 

""Die  Gymnastik  nach  dem  System  des  Sctiwedischen  Gymnasiarcheu  P.  H. 
Ling,"  1847,  pp.  69,  70. 

^ "  Die  Heilgymnastik,"  18-52,  pp.  287,  292,  &c.,  and  "  Lelirbuch  der  Leibesii- 
bungen,"  1856,  part  2,  pp.  290,  &o. 

*  "  KinesithSrapie,"  1817,  pp.  47,  &c. 

""Handbook  of  the  Movement  Cure,"  1856,  pp.  215,  &c. 

•  "  Larobok  i  Sjukgymnastik,"  1870,  p.  100  ;  1883,  pp.  102,  &c. ;  1S92,  pp.  101,  &c. 
""Die  Heilgymnastik,"  1852,  pp.  287-300. 

»  "  Handbook  of  the  Movement  Cure,"  1856,  pp.  215-220. 

'" "  Efterlemnade  Skrifter,"  1882,  pp.  167-169;  see  also  his  gymnastic  prescrip- 
tions, many  of  which  are  given  in  detail  in  that  book. 

"  "  Kinetic  Jottings,"  1880,  pp.  187,  1.38. 

'- "  Liirobok  i  Sjukgymnastik,"  1870,  pp.  101-104  ;  1883,  pp.  102-106 ;  1892,  pp. 
101-105. 

'^  Sec  Branting's  address  to  the  graduates  of  the  G.  C.  I.,  on  April  8,  1848,  and 
"Efterlemnade  Skrifter,"  1882,  pp.  145,  237. 

'•  Sec  p.  184. 

''See  Hartelius,  "Liirobok  i  Sjukg5'mnastik,"  1870,  p.  104;  1883,  p.  105; 
1892,  p.  104. 


1 82    ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

published,  althouob  some  of  them  were  described  by  Arvid 
Kellgren  ^  in  1888  and  1890. 

The  mistaken  idea  that  what  are  known  as  Kellgren's  methods 
comprised  only  vibrations  (and  no  other  form  of  movement)  seems 
to  have  arisen  during  the  period  -  defined  by  these  two  dates.  It 
is  a  point  of  interest  that  during  the  last  ten  or  twelve  years  there 
has  been  a  great  increase  in  the  use  of  machines  devised  to 
administer  mechanical  vibrations ;  new  forms  of  these  are  con- 
tinually appearing  on  the  market. 

Various  forms  of  vibrating  machines  had  been  invented  long 
before  the  days  of  P.  H.  Ling,  who  himself  refers  to  them.^ 
Zander,  of  Stockholm,  constructed  his  first  vibrator  in  1868;  Lied- 
beck's  is  of  later  date.  Mortimer  Granville's*  was  produced  in 
1882.  Since  then  some  of  the  practitioners  of  Ling's  medical 
gymnastics  in  Stockholm  *  have  at  intervals  either  advocated 
such  appliances,  or  have  stated,  without  actual  recommenda- 
tion, that  they  may  be  used  to  replace  the  hand  of  the  gymnast. 
Those  who  are  most  favourably  disposed  allege  that  vibrations 
produced  by  machines  can  be  administered  with  greater  ease, 
while  taxing  less  the  powers  of  the  gymnast,  and  that  in  con- 
sequence of  this  they  will  derive  the  advantage  of  a  more  perfect 
continuity.^ 

'  "  Vortrage  fiber  Massage,"  in  "  Statistischer  Sanitatsbericbt...fiir  1888"; 
"  Technic  of  Ling's  System  of  Manual  Treatment,"  1890. 

-  Nebel,  "  Bewegungskuren  mittelst  Schwedisoher  Heilgj'mnastik  und  Massage," 

1889,  p.  265  ;  Hasebroek,  "  Die  Ersohiitterung  in  der  Zanderschen  Heilgymnastik," 

1890,  p.  1. 

'  "  Gymnastikens  Allmanna  Grander,"  1866,  pp.  581,  585. 

'  See  "  Percussion  as  a  Therapeutic  Agent  in  Nervous  Diseases,"  in  Brit.  Med. 
Journ.,  1882,  vol.  1,  p.  39;  and  "  A  Note  on  tbe  Treatment  of  Locomotor  Ataxia 
by  Precise  Nerve-vibration,"  in  ibid.,  1882,  vol.  2,  pp.  559,  &c. 

^'Branting,  "  Efterlemnade  Skrifter,"  1882,  pp.  167,  168.  Hartelius,  "Larobok  i 
Sjukgymnastik,"  1870,  p.  100';  1883,  p.  102  ;  1893,  p.  101.  Murray,  Th.  Brandt, 
Levin,  &c.  in  Liedbeok,  "Vibratorn,  dess  .Kndamal,  Beskrifning  och  Anvaudning," 

1891,  p.  vi.  ;  "A  Description  of  the  Vibrator,"  1891,  page  vi. 

'Cf.  Hasebroek,  "Die  Erschiitterung  in  der  Zanderschen  Heilgymnastik," 
1890j  p.  2.  Murray,  Helleday,  Wide,  Zander,  Wallgren,  Levin,  and  Th.  Brandt,  in 
Liedbeck's  "Vibratorn,  dess  Andamal,  Beskrifning  och  Anvjindniug,"  1891,  pp.  vi., 
1,2;  and  Liedbeck's  "  A  Description  of  the  'Vibrator,"  1891,  pp.  vi.,  1,  2;  and  in 
Tidskrift  i  Gymnastik,  1891,  pp.  532,  533.  Levertin,  "  Dr.  G.  Zander's  Medico- 
Meohanische  Gymnastik,"  1892,  p.  40;  "Dr.  G.  Zander's  Medico-Mechanical  Gym- 
natics,"  1893,  p.  38.  Weman,  "Gymnastik  Handskakningsmaskin,"  in  Tidskrift  i 
Gymnastik,  1895,  p.  268.  Wide,  "  Handbok  i  Medicinsk  Gymnastik,"  1895,  p.  66  ; 
"  Handbook  of  Medical  Gymnastics,"  1899,  p.  65 ;  "  Handbok  i  Medicinsk  och 
Ortopedisk  Gymnastik,"  1902,  p.  62  ;  "  Handbook  of  Medical  and  Orthopfedic  Gym- 
nastics," 1903,  p.  73. 


GYMNASTIC   MOVEMENTS  183 

There  is  no  doubt  that  the  method  of  vibrating  as  employed 
by  many  of  the  practitioners  of  Ling's  system  of  to-day  is 
extremely  tiring  to  the  gymnast,  the  vibrations  being  produced 
by  strong  tetanic  contractions  of  the  muscles  of  the  whole  arm 
and  shoulder'  (see  p.  139). 

As,  however,  Kellgren's  vibrations  are  in  the  majority  of  cases 
given  from  the  wrist  and  finger-joints,  with  almost  imperceptible 
contraction  of  the  forearm  muscles  (see  p.  136),  they  involve  but 
slight  exertion  on  the  part  of  the  assistant,  who  can  continue  to 
apply  them  as  long  and  as  evenly  as  in  practice  is  desired.  Per- 
sonally, I  have  never  given  vibrations  uninterruptedly  for  more 
than  one  hour  and  three  quarters  :  but  I  am  confident  that  I  could 
maintain  them  for  several  hours  if  necessary.  The  great  reason 
for  preferring  Kellgren's  manual  vibrations  is  that  the  assistant, 
having  his  sense  of  touch  to  guide  him,  can  modify  the  strength, 
excursion  and  rate  of  the  movement  at  any  given  moment  should 
this  become  necessary.  In  some  cases  of  great  amount  of  pain 
from  acute  inflammation,  say  in  the  eyes  or  peritoneum,  it  is 
impossible  to  adjust  accurately  the  strength  of  the  machine 
vibrations,  and  certainly  none  of  the  advocates  of  the  latter  have 
ever  recommended  them  for  such  pathological  conditions.  In 
some  machine  institutes  even  head  and  throat  vibrations  are 
given  with  the  gymnast's  hand  placed  between  the  vibrator  and 
the  part  of  the  patient  to  be  vibrated. 


Physiological  Effects   of  Manual   Shakings   aoid    Vibrations   on 
Structures  other  than  Nerves. 

It  is  impossible  to  make  any  comprehensive  statement  under 
this  head,  as  the  effects  vary  greatly  with  regard  to  diiiferent 
organs.  Speaking  generally,  both  shakings  and  vibrations  (except- 
ing the  "suction"  and  "nipping"  forms)  promote  the  lymph 
and  venous  circulation,  vibrations  tending  to  cause  vaso-con- 
striction  of  the  arterial  vessels ;  shakings  are  more  stimulatory 
and   vibrations   more  soothing,  the   former  being  indicated   for 


'  Whether  Hj.  Ling  and  Branting  actually  used  this  method  I  cannot  say ;  but 
it  seems  probable  from  Neumann's  descrii^tion  that  they  did  (see  "Die  Heil- 
gymuastik,"  1852,  pp.  288,  &o).  No  precise  details  concerning  the  method  o£ 
vibrating  can  be  found  in  the  writings  of  Branting,  Georgii,  Rothstein,  Roth, 
Hj.  Ling,  or  Hartelius. 


i84    ELEMENTS  OF  KELLGREN'S  MANUAL  TREATMENT 

chronic  inflammations  and  lowered  vitalitj-,  the  latter  for  acute 
conditions. 

Shakings  executed  from  side  to  side  have  a  much  more  super- 
ficial efl^ect  than  those  which  are  executed  up  and  down  and  thus 
penetrate  to  the  deeper  tissues.  The  effects  of  suction  vibrations, 
nipping  vibrations,  friction  vibrations,  and  friction  vibrations  with 
suction,  have  already  been  alluded  to  when  considering  the  modus 
operandi  (see  pp.  140  to  144). 

The  subject  is  one  that  has  been  only  partially  investigated, 
and  further  researches  will  be  necessary  before  any  far-reaching 
generalisations  can  be  made.  A  good  deal  of  work  has  been  done 
on  the  Continent  in  connection  with  vibrations  effected  by  means 
of  machines,  but  what  is  true  of  machine  vibrations  is  not 
always  true  of  manual  ones.  Some  authors,  for  example,  employ 
machine  vibrations  in  order  to  increase  the  temperature  of  the 
part  manipulated ;  whereas  the  result  of  Kellgren's  manual 
vibrations  is  in  almost  every  case  to  effect  a  decrease  in  this 
respect. 

Special  effects  on  special  organs  will  be  referred  to  when 
describing  the  actual  methods  of  manipulation. 


Methods  of  Executing  the  various  Vibrations  and  Shakings 
on  Structures  other  than  Nerves. 

(1)     On  the  Head. 

A  kind  of  head  vibration  was  formerly  used  by  the  Ling 
school.  Branting^  mentions  head  lifting  and  shaking  com- 
bined with  active  trunk  extension  (see  p.  181),  followed  by 
double  jugular  vein  pressure.  Eoth-  says :  "  Head  vibration  is 
generally  combined  with  passive  alternate  head  turning.  The 
gymnast  stands  on  one  side  of  the  patient,  by  placing  one  hand 
on  the  forehead,  and  the  other  on  the  back  part  of  the  head,  he 
turns  it  first  to  one  and  then  to  the  other  side,  and  at  the  same 
time  vibrates  it.  The  vibration  is  done  for  some  seconds,  and, 
after   a   pause,  repeated   two  or  three   times."    Neumann  ^  also 

'  See  his  address  to  the  graduates  of  the  G.  C.  I.,  April  8th,  1848. 
^"  Handbools  of  the  Movement  Cure,"  1856,  pp.  215  and  216. 
3"  Die  Heilgymnastik,"  1852,  p.  291. 


GYMNASTIC   MOVEMENTS  185 

describes  the  above  in  bis  writings.  The  manipulation,  however, 
seems  to  have  been  abandoned,  for  in  Hartelius'  "  Larobok  i 
Sjukgymnastik,"  1870,  1883,  1892,  no  such  exercise  is  described, 
nor  does  Wide  mention  anything  like  it  in  his  handbooks. 

Kellgren's  head  vibration. — The  parts  of  the  head  usually 
vibrated  are  the  frontal,  parietal  and  occipital  regions.  The 
assistant  places  the  terminal  phalanges  of  three  or  four  fingers 
on  either  of  the  first  two  regions  mentioned,  and  those  of  the 
other  hand  on  the  last ;  he  then  sets  up  the  vibrations  in  the 
usual  way.  A  certain  amount  of  pressure  on  the  scalp  is  necessi- 
tated (as  mentioned  on  p.  138) ;  the  pressure  may  vary  from 
gentle  to  very  strong,  according  to  circumstances. 

Vibrations  on  the  medulla  may  be  executed  with  the  finger  tips 
placed  in  the  nape  of  the  neck  below  the  occipital  protuberance. 
Vibrations  may  also  be  given  on  any  other  part  of  the  head  in 
order  to  specially  affect  any  localised  area  of  the  brain. 

(2)     On  the  Eyes. 

Either  one  or  both  hands  may  be  used.  In  each  case  the 
patient  closes  his  eyes.  The  assistant,  while  executing  the 
vibrations,  must  take  care  not  to  move  the  patient's  eyelids  up 
and  down,  but  to  keep  them  steady  on  the  eyeball,  otherwise  the 
manipulation  becomes  irritating  and  painful,  and  also  fails  to 
achieve  more  than  a  superficial  effect.  A  properly  executed  eye 
vibration,  even  with  so  small  an  excursion  as  to  be  barely  visible 
unless  closely  viewed,  can  be  clearly  felt  by  the  hand  of  a  third 
person  through  the  back  of  the  patient's  head. 

When  using  only  one  hand,  the  assistant  stands  at  the  side  of 
the  patient  and  places  the  terminal  phalanx  of  the  thumb  on  one 
eye  and  the  terminal  phalanx  of  the  first  and  second  fingers  on 
the  other  eye;  then  the  vibrations  are  set  up. 

When  using  both  hands  the  assistant  stands  behind  the 
patient  and  places  the  last  two  phalanges  of  the  second  and 
third  fingers  of  each  hand  over  the  upper  and  lower  eyelids  of 
each  side  respectively ;  then  the  vibrations  are  set  up. 

Bilateral  vibration,  with  the  fingers  of  each  hand  placed 
respectively  on  each  side  of  the  orbit  over  the  great  wing  of  the 
sphenoid  bone,  can  also  be  used,  with  the  special  object  of 
affecting  the  deeper  lying  parts  of  the  eyeball  and  the  optic 
nerve. 


l86    ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

(3)    On  the  Nose. 

The  assistant  may  vibrate  the  root  of  the  nose  with  the  fore- 
finger and  thumb  ;  by  means  of  this  he  will  often  be  able  to  stop 
an  attack  of  epistaxis.  One  of  the  most  rapid  cures  I  have  known 
took  place  with  a  girl,  aged  17,  who  usually  had  such  attacks 
twice  a  day,  sometimes  three  times ;  the  condition  had  persisted 
for  a  year.  She  received  one  treatment  only,  consisting  of  nose 
root  shaking  and  head  lifting,  lasting  about  fifteen  minutes. 
Two  years  have  elapsed  since  then,  but  she  has  never  been 
troubled  again  with  any  bleeding  (see  also  pp.  48,  49). 

Fronto-nasal  Running  Vibration. 

One  of  the  assistant's  hands  begins  high  up  on  the  inner  part 
of  the  frontal  eminence  ;  the  fingers  travel  vertically  downwards 
across  the  sides  of  the  glabella,  upper  inner  angle  of  the  orbits, 
along  the  sides  of  the  nasal  bones,  and  then  diverge  as  they  go 
down  the  sides  of  the  nose,  an  energetic  vibration  being  mean- 
while maintained.  This  may  be  followed  by  running  vibrations 
or  frictions  on  the  supraorbital,  supratrochlear,  infratrochlear  and 
nasal  nerves.  The  other  hand  may  either  be  used  to  support  the 
head  or  to  execute  vibrations  or  shakings  on  the  coronal  suture. 
There  is  in  many  persons  a  small,  quite  well-defined  area  in  the 
latter,  on  which  shaking  causes  sensation  inside  the  nose. 

This  manipulation  produces  a  loosening  of  the  mucus,  and  a 
tendency  to  diminution  of  any  congestion  of  the  mucous  mem- 
brane of  the  nose.  It  is  thus  of  advantage  in  coryza.  With 
patients  suffering  from  meningitis  or  other  acute  conditions  of 
the  brain  accompanied  by  increased  intracranial  pressure  this 
running  vibration  in  particular  should  be  resorted  to  ;  frequently 
the  discharge  from  the  nose  will  be  greatly  increased,  some 
haemorrhage  ensaing  that  will  improve  the  condition.  Whether 
the  discharge  consists  in  part  of  cerebro-spinal  fluid  I  cannot 
say  with  certainty.^ 

(4)  On  the  Superior  Maxilla. 

Vibrations  may  be  administered  on  this  in  cases  of  antral 
abscess.     The  assistant   stands    behind   the   patient  ;    he   places 

'  Cf.  St.  Clair  Thomson,  "  The  Cerebro-spinal  Fluid,  its  Spontaneous  Escape  from 
the  Nose,"  1899. 


GYMNASTIC    MOVEMENTS  187 

the  fingers   of  his  one  hand   horizontally   over  the   cheek,   and 
then  sets  up  the  vibrations. 

(5)  On  the  Ear*  and  Adjacent  Parts. 

(a)  On  the  meatus  itself. — The  assistant  standing  in  front  of 
the  patient,  places  the  tip  of  the  fore  or  little  finger  in  the 
meatus  and  vibrates  in  a  forward  direction. 

(b)  On  the  meatus  through  the  tragus. — Standing  in  front  of 
the  patient,  the  assistant  places  the  tips  of  one  or  two  fingers 
on  the  tragus,  presses  it  inwards  so  as  to  occlude  the  external 
opening  of  the  meatus,  and  then  vibrates. 

(c)  On  the  whole  pinna  and  external  meatus. — The  assistant 
stands  in  front  of  the  patient  and  grasps  the  pinna,  so  that  the 
last  phalanx  of  his  thumb  and  forefinger  lie  respectively  on  the 
concha  and  on  the  corresponding  posterior  surface  of  the  ear. 
Drawing  the  pinna  outwards  so  as  to  stretch  the  external  meatus, 
he  then  administers  the  shakings. 

{d)  On  the  external  meatus  froin  behind. — The  assistant  stands 
in  front  of  the  patient  and  places  the  tips  of  his  fingers  behind 
the  root  of  the  ear  in  front  of  the  mastoid  process.  He  then  sets 
up  the  vibrations  or  shakings  forwards  and  upwards. 

(e)  On  the  mastoid. — The  assistant,  placing  the  tips  of  two 
fingers  on  the  mastoid  process,  sets  up  the  usual  vibrations  or 
shakings. 

(6)  On  the  Pharynx. 

The  pharynx  may  be  shaken  or  vibrated  in  several  different 
ways. 

(«)  The  palmar  aspects  of  the  terminal  phalanges  of  the  first 
and  second  fingers  are  placed  on  each  side  respectively,  just 
internal  to  the  angle  of  the  lower  jaw.  Keeping  the  whole  hand 
horizontal,  the  shakings  or  vibrations  are  executed  in  an  upward 
and  forward  direction. 

{b)  The  palmar  aspects  of  the  thumb  and  fingers  of  one  hand 
are  placed  on  each  side  respectively,  far  back  between  the  hyoid 
bone  and  the  angle  of  the  jaw.  The  shakings  or  vibrations  are 
then  given  laterally. 

(c)  The  palmar  aspects  of  the  tips  of  the  fingers  of  each  hand 
are   placed    on    either   side   respectively   behind    the    ascending 


i8S    ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

ramus  of  the  jaw,   and   the  shakings  or  vibrations   given  in  a 
dovfnward  direction. 

These  luanipulations  also  influence  the  tonsils. 

(7)     On  the  Salivary  Glands. 

(a)  The  parotid  gland. — The  fingers  of  the  assistant  are  placed 
in  the  same  position  as  in  (c)  (for  the  pharynx),  and  the  shakings 
or  vibrations  executed,  generally  in  a  downward  direction. 

(b)  The  submaxillary  gland. — The  palmar  aspects  of  the  ter- 
minal phalanges  of  the  first  and  second  fingers  are  placed 
respectively  on  each  side  internal  to  the  lower  jaw,  about  midway 
between  its  angle  and  the  mentum.  Shakings  or  vibrations  in 
an  upward  and  forward  direction  are  then  administered. 

(c)  The  sublingual  gland.  —  The  palmar  aspects  of  the 
terminal  phalanges  of  the  first  and  second  fingers  are  placed  close 
together  behind  the  mentum,  and  shakings  or  vibrations  adminis- 
tered in  an  upward  and  forward  direction. 

(8)     On  the  Larynx  and  Trachea. 

(a)  The  larynx. — May  be  vibrated  or  shaken  with  the  fingers 
and  thumb  placed  respectively  on  either  side  of  the  thyroid 
cartilage. 

{b)  The  trachea  {high  up). — May  be  treated  in  the  same  way 
with  the  finger  and  thumb  on  either  side.  In  both  cases  the 
shakings  should  be  given  in  a  lateral  direction. 

(c)  The  trachea  {low  down). — The  tips  of  the  fingers  are 
placed  in  the  suprasternal  notch,  and  the  shakings  executed  in  a 
sideways  and  upwards  direction. 

Bimanual  vibration  of  the  larynx  and  trachea. — This  may 
also  be  made  use  of  in  some  cases.  The  assistant  standing 
behind  the  patient  places  the  tips  of  all  the  fingers  of  both  hands 
respectively  on  either  side  of  the  larynx  or  trachea,  and  then  sets 
up  the  vibrations. 

(9)     On  the  Thyroid  Gland. 

In  cases  of  enlarged  thyroid  gland  or  the  thyroid  of  exophthal- 
mic goitre,  vibrations  are  executed  as  follows  : — The  thumb  and 
fingers  of  one  of  the  assistant's  hands  close  on  the  gland,  and 


GYMNASTIC   MOVEMENTS 


189 


then  lift  it  somewhat  upwards  ;  suction  vibrations  are  then  given 
in  an  upward  and  inward  direction.  In  cases  of  atrophic  con- 
ditions of  the  gland,  shakings  are  substituted  for  vibrations. 

(10)  On  the  Arm. 

Vibration  of  the  whole  arm  with  simultaneous  traction  has 
been  described  (p.  115). 

(11)  On  the  Leg. 

Vibration  of  the  leg  with  simultaneous  traction  has  been 
described  (p.  11.5). 

(12)     On  one  Lateral  Half,  op  on  the  Whole  of  the  Body. 

Vibration  on  one  lateral  half,  or  on  the  whole  of  the  body, 
with  simultaneous  traction  has  been  described  (pp.  115,  116). 

(13)     On  the  Thorax. 

There  are  two  different  manipulations. 

(a)  Shaking  of  the  lower  part  of  the  thorax  (conwionhj  called 
side  shaking). — This  is  usually  given  with  the  patient  in  heave 
grasp  standing  or  half  lying  position.  The  assistant  stands 
in   front   of  the  patient   as   in  fig.  75,  his   hands   being  placed 


I90    ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

laterally  on  the  lower  ribs  of  each  side  respectively.  Continu- 
ally drawing  the  ribs  slightly  forwards,  he  makes  a  series  of 
soft  elastic  pressures  downwards,  inwards  and  forwards,  relax- 
ing between  each.  During  the  relaxations  the  hands  must  not  be 
moved  on  the  thorax,  but  must  maintain  the  original  close  con- 
tact. The  elasticity  of  the  ribs  causes  them  to  rebound  each  time 
the  pressure  is  removed,  and  thus  air  is  alternately  pumped 
out  and  in  of  the  lower  part  of  the  lungs.  The  pleurae  are 
also  affected,  and  immobility  from  adhesions  will  give  way  to 
mobility,  the  adhesions  themselves  being  gently  broken  down. 
The  arrangement  of  the  lymphatics  of  the  intercostal  spaces 
will  aid  in  the  absorption  of  the  morbid  products  (see  pp.  8.3,  84). 
The  upper  abdominal  organs  will  also  be  subjected  to  alternating 
application  and  removal  of  pressure. 

Side  shaking  as  given  above  has  a  quieting  effect  on  excited 
cardiac  action ;  it  is  difficult  to  say  whether  this  is  due  to  pro- 
motion of  the  pulmonary  circulation,  to  direct  effect  on  the  heart, 
to  reflex  effect  on  the  heart  through  the  sensory  nerves,  or  to  a 
combination  of  two  or  more  of  the  above. 

(b)  Vibration  and  shaking  of  the  upper  part  of  the  thorax. — 
The  position  of  the  patient  is  the  same  as  for  side  shaknig.  The 
palmar  aspect  of  the  hand  is  placed  anteriorly  over  the  middle  of 
the  chest  or  over  any  part  that  is  specially  affected,  and  the  ma- 
nipulation is  then  executed  in  a  somewhat  downward  direction. 
Its  strength  depends  upon  the  nature  of  the  malady ;  either 
shaking  or  vibration  may  be  prescribed  for  chronic  conditions, 
but  as  a  general  rule  for  acute  ones  only  vibration  is  employed. 
The  other  hand  of  the  assistant  may  be  used  either  to  vibrate 
posteriorly  between  the  shoulder  blades  of  the  patient  or  over 
any  other  part  that  is  specially  affected,  or  to  administer  inter- 
scapular nerve  frictions. 

(14)  On  the  Heart. 

The  patient  is  usually  placed  in  half  lying  or  heave  grasp 
standing  position  before  administering  the  ensuing  manipulations. 

(a)  Shaking  of  the  heart. — The  assistant's  right  hand  is  placed 
on  the  front  of  the  left  half  of  the  thorax  low  down,  so  that  the 
thumb  is  over  the  xiphisternum,  and  the  fingers  somewhat  spread 
out  over  about  the  fifth  to  eighth  ribs  laterally,  as  in  fig.  76.  The 
shaking  is  then  given  gently  downwards,  forwards  and  inwards. 


GYMNASTIC   MOVEMENTS  191 

(b)  Vibration  of  the  heart- — Vibrations  may  be  given  with  the 
hand  in  the  same  position  as  for  shaking,  or  the  hand  may  be 
placed  over  the  heart  itself. 

(c)  A  combination  of  (a)  and  (b)  may  be  used. 

The  effect  of  the  above  manipulations  is  to  improve  the  tone 
of  the  heart  muscle  so  as  to  bring  it  to  a  condition  in  which  there 
is  a  good  systolic  contraction  and  a  normal  diastolic  period. 


Kellgren's  heart  vibration  and  shaking  has  a  similar  effect  to 
the  local  heart  treatment  of  the  Ling'  school,  which  from  its 
physiological  effect  has  been  termed  "Branting's  digitalis." 

How  can  the  physiological  effect  of  vibration  and  other  ma- 
nipulations over  the  heart  be  explained  ?  Some  have  regarded  the 
whole  phenomenon  as  being  a  reflex  through  the  sensory  nerves, 
the  medulla,  and  the  vagus.     (Murray,^  Lorand.^)    I  cannot,  how- 

'  Sec  Georgii,  "  Kinesitherapie,"  1847,  p.  84. 

■-'"Pa  hvilka  fysiologiska  grander  hvilar  en  ratt  gj-mnastisk  behandling  af 
organiska  hjertsjukdomar,"  in  Tidskrift  i  Gymnastik,  1887  (pp.  603-613),  p.  611. 

s"  tjber  die  Manuelle  Behandlung  der  Herzkraukheiteu,"  in  Wien.  Med.  Pressc, 
1895,  Nos.  40  and  41. 


192    ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

ever,  allow  that  this  is  the  only  channel  of  communication 
involved,  although  prepared  to  admit  that  it  may  be  a  minor 
one.  If  the  theory  specified  were  correct,  the  same  phenomena 
in  the  heart  should  result  from  executing  the  manipulation  on  the 
corresponding  right  side  of  the  body ;  this,  however,  is  not  the 
case.'  I  am  of  the  opinion  that  a  great  deal  of  the  effect  of  heart 
vibration  is  due  to  direct  transmission  of  the  propagated  vibrations 
to  the  heart  itself,  and  that  the  vibrations  act  by  tending  to 
restore  the  normal  equilibrium  between  the  two  sets  of  fibres, 
augmentor  and  inhibitory,  which  has  become  disturbed  through 
increased  or  decreased  excitability  of  either  of  them.  A  number 
of  statistics  concerning  the  effect  of  heart  vibration,  as  given  by 
the  Ling  school,  in  cases  of  organic  cardiac  disease  (taken  from 
patients  under  treatment  at  the  G.  C.  I.)  have  been  published  by 
Levin  ;  the  reader  is  referred  to  these. ^ 

(15)  On  the  Spinal  Coi-'d. 

In  the  case  of  any  acute  inflammatory  condition,  &c.,  of  the 
spinal  cord,  vibrations  may  be  given  on  the  seat  of  the  lesion  (as 
determined  from  the  symptoms)  with  the  finger  tips  placed  close 
to  the  middle  line  on  either  side  of  the  spines  of  the  overlying 
vertebras. 

(16)  On  the  Abdomen  in  Whole  op  in  Part. 

(rt)  On  tlte  abdomen  as  a  luhole. — The  assistant's  hand  is  placed 
over  the  front  of  the  patient's  abdomen  in  about  its  middle,  the 
fingers  being  spread  out  so  as  to  obtain  the  greatest  range  possible. 
The  hand  may  exercise  a  fair  amount  of  pressure  and  apply  shak- 
ings, or  may  rest  very  lightly,  and  instead  administer  vibrations. 
The  former  manipulation  is  stimulatory  ;  the  latter  sedative. 

(h)  On  the  pit  of  the  stomach  (oiien  called  subcostal  shaking). 
— The  assistant's  fingers  are  placed  in  the  subcostal  triangle, 
and  shakings  executed  in  a  backward  and  downward  direction 
(fig.  77.)     The  solar  plexus  is  influenced  by  this,  as  also  are  the 

'  It  would  be  of  interest  to  stud}'  the  effect  of  this  manipulation  in  such  cases  as 
complete  transverse  myelitis  above  the  fifth  dorsal  vertebra,  in  which  all  propaga- 
tion of  sensation  to  the  medulla  is  eliminated. 

- "  Bidrag  till  kiinnedomen  om  sjukgymnastiska  rorelsers  iuverkau  pa  rytmen 
vid  organiska  hjertfel,"  in  Tidskrifl  i  Gymnastik,  1892  (pp.  698-704),  pp.  702,  &c. 


GYMNASTIC    MOVEMENTS  193 

and    siaasm   of   the    diaphragm   can 


duodenum,    pancreas,    &c 
be  reUeved  by  its  means. 

(c)  On  the  liver. — See  p.  'iSl. 

(d)  On  the  rjall-hladder. — See  p.  231 
{e)  On  the  S2)Ieen. — See  p.  232. 

(/■)  On  the  l-idneijs.—See  p.  232. 


(fj)  On  tlie  bladder. — See  p.  itJ8. 

(/i)  On  the  male  genital  organs. — See  p.  233. 

(j)  On  the  female  genital  organs. — See  pp.  235,  &c. 

(j)  On  the  anus. — See  p.  233. 

(fc)  On  the  anal  canal. — See  p.  233. 


(17)  Ovei"  Ulcer's  and  Wounds,  &c. 

A  piece  of  hnt  is  placed  l^etweeu  the  hand  of  the  assistant  and 
the  ulcer  (or  wound,  &c.),  and  the  vibrations  given  through  it. 
They  appear  to  materially  hasten  the  healing  process. 

(18)  Around  Abscesses. 

Suction  vibrations  should  be  given  in  such  cases.     They  keep 
the  abscess   from   spreading,  and   hinder   the   absorption   of  its 
13 


194  ELEMENTS    OF   KELLGREN'S   MANUAL   TREATMENT 

products.  Pointing  takes  place  more  quickly,  and  thus  the 
abscess  opens  sooner  ;  after  it  has  done  so  the  pus,&c.,  is  removed 
more  painlessly  and  completely. 

(19)  On  Joints. 

Several  kinds  of  vibration  and  shaking  of  joints  are  used,  as 
follows  : — 

(1)  Stationanj  vibrations  can  be  executed  by  placing  the  fingers 
on  the  joint ;  the  vibrations  will  be  transmitted  to  it. 

(2)  Vibratory  traction.  —  One  hand  is  placed  immediately 
above  the  joint,  and  the  other  below  it ;  then,  maintaining  trac- 
tion, simultaneous  vibration  is  set  up  with  both.  An  extremely 
fine  alternating  flexion  and  extension,  abduction  or  adduction,  or 
rotation,  with  traction,  is  effected  at  the  joint. 

(3)  Shaking  with  traction. — If  shaking  be  substituted  for 
vibration  in  (2),  the  eiJect  is  increased  owing  to  the  greater 
excursion  of  the  movement. 

(4)  Vibration  tcith  simultaneous  gentle  passive  movement  at 
the  joint. — One  hand  vibrates  the  joint  as  in  (1)  ;  the  other 
keeping  up  traction  performs  passive  slow  flexion  and  extension, 
abduction  and  adduction,  or  rotation,  at  first  through  the  smallest 
range,  but  soon  gradually  increasing  it. 

In  cases  of  very  painful  joints  or  apparent  anchylosis,  it  is 
sometimes  possible  by  "persuasion,"  with  the  above  methods,  to 
gradually  re-establish  the  normal  amount  of  movement.  They 
will  often  succeed  when  force  will  do  nothing,  owing  to  the 
muscular  contraction  that  results,  in  part  reflex,  and  in  part  direct 
from  the  pain  induced. 

III. — Fbictions  on  Other  Structures. 

By  friction  is  meant  not  "  massage  "  in  the  strict  sense  of  the 
word  (see  p.  210),  but  a  manipulation  resembling  a  nerve  friction, 
the  fingers  being  drawn  sharply  across  the  structure  under  treat- 
ment, thus  stimulating  it. 

Frictions  on  Muscles. 

One  of  the  muscles  on  which  frictions  are  most  frequently 
employed    is   the   erector   spinae    and    its   various   sub-divisions. 


GYMNASTIC  MOVEMENTS  195 

The  patient  first  assumes  some  position  such  as  forwards  lying, 
in  which  the  muscles  specified  are  relaxed  ;  the  assistant,  placing 
his  fingers  or  thumb  over  these  muscles,  close  to  the  spines  of 
the  vertebras,  gives  the  frictions  from  within  outwards.  If  it  is 
desired  to  stimulate  one  special  segment  of  the  muscle  the 
manipulation  is  repeated  as  above  several  times  on  the  same 
spot ;  but  if  it  is  desired  to  affect  the  erector  spinae  as  a  whole, 
the  assistant  begins  in  the  upper  dorsal  region,  and  passing 
downwards  administers  a  friction  opposite  each  vertebra  until 
the  lower  part  of  the  sacrum  is  reached. 

In  a  similar  manner  frictions  may  be  administered  on  any 
other  muscle  that  does  not  lie  too  deep. 

The  effect  is  stimulatory.  The  muscles  are  excited  to  con- 
traction, a  vaso-dilatation  ensues  in  them,  and  their  venous  and 
lymphatic  flow  is  furthered ;  any  nerve  trunks  that  lie  in  the 
substance  of,  or  immediately  in  contact  with  the  muscle  are 
stimulated,  being  affected  much  as  in  the  case  of  nerve  friction 
In  most  cases  of  paralysis  agitans,  frictions  on  the  extensors 
on  the  back  of  the  forearm  can  entirely  remove  the  tremors 
for  a  few  seconds.  In  normal  persons  frictions  on  these  muscles 
generally  bring  about  a  contraction  in  the  same. 


Trunk  Stretching,  PA,  Spinal  Muscle  Frictions,  PP. 

This  movement  is  prescribed  for  spinal  curvatures.  The 
patient  assumes  either  half  lying,  reach  grasp,  or  stretch  grasp 
standing  position,  and  then  stretches  himself  to  his  utmost, 
so  as  to  straighten  his  vertebral  column  as  much  as  possible. 
While  the  patient  does  this  the  assistant  gives  strong  frictions 
near  to  the  spine  on  the  muscles  (this  will  include  the  nerves) 
situated  at  the  point  of  greatest  convexity  of  the  curve  (or 
curves,  if  there  are  more  than  one),  i.e.,  where  the  muscles  are 
weakest. 

The  spinal  curvature  tends  to  be  corrected,  because  the 
patient,  while  trying  to  straighten  the  vertebral  column,  makes 
use  of  the  weakened  muscles,  which  will  be  exercised  at  the 
expense  of  their  contracted  and  stronger  antagonists.  The 
manipulation  of  the  assistant  aids  the  process  by  stimulating 
the  weakened  muscles  in  question. 


196     ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

Frictions  on  the  Salivari/  Glands. 

The  position  of  the  assistant's  fingers  is  the  same  as  for  vibra- 
tions and  shakings  on  these  structures  (p.  188).  The  direction  of 
the  frictions  is  as  follows  : — • 

(1)  Parotid  gland  ;  downwards. 

(2)  Submaxillary  gland  ;  forwards. 
(8)   Sublingual  gland  ;  forwards. 

Frictions  on   tJic  Abdominal  and  Pelvic  Organs. 
These  will  be  described  on  pp.  231,  &c. 

Frictions  round   Ulcers. 

Friction  vibrations,  or  friction  vibrations  with  suction  can 
be  made  use  of.     The  method  has  been  descril)ed  on  p  143. 


GYMNASTIC  MOVEMENTS 


HACKING,  CLAPPING  AND  BEATING. 

The  various  exercises  indicated  by  the  above  titles  have 
been  incUided  by  some  writers  under  the  comprehensive  term 
"  tapotement."  There  are,  however,  well-defined  differences 
between  Kellgren's  methods  and  those  of  other  schools. 

Hacking,  clapping  and  beating  may  be  defined  as  the 
administering  in  rapid  succession  of  a  series  of  short,  sharp, 
elastic  strokes  with  the  hands.  It  is  of  the  greatest  importance 
that  the  finger,  wrist  and  elbow-joints  be  kept  loose  during 
the  process  ;  otherwise  the  manipulation  becomes  one  of  banging, 
thumping  and  bruising. 

Hacking. — Takes  place  thus  :  the  forearm  is  in  the  mid- 
position  with  the  fingers  slightly  separated  from  one  another  and 


somewhat  flexed  in  all  the  phalangeal  joints,  each  inner  finger 
being  more  flexed  than  its  outer  neighbour.  As  the  hand  goes 
to  the  part  to  be  hacked  the  forearm  is  supinated  a  little,  so  that 
the  dorso-ulnar  surface  of  the  fingers  meet  it  (fig.  78). 

In  confirmation  of  the  statement  in  par.  1,  above,  it  may,  for 
example,  be  pointed  out  that  this  method  is  quite  different  from 


I9S    ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

that  of  Hoffa.  He  says  (the  passage  is  translated),'  "  Hackin<( 
(tapotement)  takes  place  as  follows  :  both  hands  of  the  masseur, 
kept  in  the  mid-position  between  pronation  and  supination,  are 
held  vertically  over  the  part  to  be  treated.  While  bringing  them 
into  complete  supination,  the  abducted  finger  tips,  without  too 
much  force  but  with  a  fair  amount  of  speed,  and  above  all  very 
elastically,  hack  the  part  of  the  body  in  question.  While  doing 
this  the  finger  and  wrist-joints  should  be  kept  as  stiff  as  possible, 
and  as  a  consequence  the  shoulder-joint  takes  a  more  active  part." 
(The  italics  are  mine. — E.  F.  C.) 


It  may  be  added  that  the  illustration  given  by  Hoffa  does 
not  correspond  with  the  description.  Such  discrepancies  are, 
however,  frequently  met  with  in  works  on  massage  and 
gymnastics.' 

Clapping. — The  principle  is  the  same  as  for  hacking,  but 
the  whole  palmar  aspect  of  the  hand  and  fingers  (which  are 
slightly  flexed)  is  used  (fig.  79). 

Beating. — The  principle  is  the  same  as  for  hacking  and 
clapping,  but  the  loosely-closed  fist  is   used  ;    the  dorsal  aspect 


'  "  Tecliuik  der  Massage,"  1897,  pp.  1.3  and  14;  see  also  his  "  Kinesitheraiiie," 
1898,  p.  489. 

^  It  is  very  curious  to  see  in  such  works  the  same  iUustrations,  often  with  different 
descriptions  pertaining  to  them,  appearing  in  successive  works  by  different  authors. 
Some  are  so  repeatedly  encountered  that  they  may  be  regarded  as  forming  a  kind  of 
stock  set. 


G  YMNA  S  TIC  MO  YEMEN  TS 


199 


of  the  last  two  phalanges  of  all  the  fingers  and  the  proximal 
part  of  the  palm  meet  the  surface  it  is  desired  to  stimulate 
(fig.  80.) 

Hacking  and  clapping  are  administered  with  both  hands,  the 
strokes  being  delivered,  as  a  general  rule,  with  each  hand  alter- 
nately ;  beating,  however,  is  nearly  always  administered  with  only 
one  hand. 


The  effect  of  the  above  manipulations  is  in  each  case  stimu- 
latory. The  vessels  and  nerves  of  the  skin  will  be  stimulated, 
especially  by  clapping.  The  vibrations  set  up  by  the  manipu- 
lations will  be  propagated  to  the  underlying  structures,  i.e.,  the 
muscles,  nerves,  vessels,  &c-,  and,  in  the  case  of  the  trunk,  to  the 
viscera  and  spmal  cord.  The  individual  muscle  fibres  are  urged 
to  greater  activity,  and  actual  contraction  may  take  place  ;  this  is 
partly  due  to  direct  effect  on  the  muscular  tissue.  The  effect 
on  the  deeper  lying  arteries  is  first  vaso-constriction,  then  vaso- 
dilatation, and  finally  a  return  to  the  original    state.      As  first 


200    ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

shown  by  Gubler\  backing  over  distended  veins  causes  them  to 
contract. - 

Further  details  as  to  effect  will  be  given  in  connection  with 
the  individual  parts  specified. 

I. — Hacking. 

(1)  Shoulder  hacliing. — The  strokes  are  administered  on  both 
sides  of  the  body  above  and  between  the  shoulders.  The  patient 
may  either  be  in  reach  grasp  stoop  fall  standing,  or  forwards 
lying  position,  &c.,  i.e.,  one  in  which  the  dorsal  muscles  are 
relaxed,  or  he  may  do  some  active  exercise  such  as  reach  grasp 
stoop  fall  standing  double  elbow  flexion  and  extension,  PA, 
during  the  course  of  the  manipulation. 

(2)  Back  hacking. — Is  administered  simultaneously  on  both 
sides  of  the  spinal  column  from  the  uppermost  dorsal  down  to  the 
lowest  lumbar  vertebra,  and  then  back  again.  The  patient  may 
be  in  reach  grasp  stoop  fall  standing  position,  or  may  perform 
some  suitable  active  exercise,  such  as  the  one  just  mentioned,  or 
stretch  stride  standing  bending  forwards,  PA,  &c.  (fig.  78). 

(3)  Hacking  of  the  whole  posterior  surface  of  the  body  (often 
called  length  hacking). — Is  administered  simultaneously  on  both 
sides  of  the  body  from  shoulders  to  heels.  The  position  of  the 
assistant's  hands  varies  with  regard  to  the  different  regions 
traversed.  In  the  interscapular  regions  they  are  kept  with  their 
long  axes  parallel  to  one  another  and  to  the  spine ;  in  the  lower 
dorsal  region  the  hands  are  somewhat  separated,  and  their  direc- 
tion is  gradually  changed  so  that  in  the  kidne}'  region  they  lie 
W'ith  their  long  axes  at  right  angles  to  the  long  axis  of  the  body. 
In  this  attitude  one  hand  passes  down  the  posterior  aspect  of  the 
gluteal  region  and  the  left  leg  to  the  ankle-joint,  while  the  other 
passes  down  the  corresponding  parts  of  the  right  limb. 

'  "  Contractilite  des  veines,"  in  Comptes  rend,  de  la  Societe  de  Biulogie,  1849 
pp.  79,  80.  See  also  Hill,  "  The  Mechanism  of  the  Circulation  of  the  Blood,"  in 
Schafer's  Text-book  of  Physiology,  vol.  ii.,  1900,  p.  119. 

-  Cf.  Wide,  "Handbook  of  Medical  and  Orthoptedic  Gymnastics,"  1903,  p.  45, 
who  says,  concerning  hackings,  "  On  the  whole,  they  have  a  stimulating  effect, 
which  can  probably  be  explained  from  the  fact  that  at  each  stroke  a  number  of 
peripheral  nerves  are  affected."  See  also  "  Handbok  i  Medicinsk  Gymnastik,"  1895, 
p.  38;  "Handbook  of  Medical  Gymnastics,"  1899,  p.  -37  ;  "Handbok  i  ■Medicinsk 
och  Ortopedisk  Gymnastik,"  1902,  p.  36. 


GYMNASTIC  MOVEMENTS  201 

(4)  Hacking  over  the  himbar  region. — Is  administered  over  the 
parts  between  the  last  ribs  and  the  crests  of  the  ilia.  It  may 
take  place  with  the  patient  passive,  such  as  in  forwards  lying 
position,  or  while  an  active  exercise  is  being  performed,  such 
as  stretch  stride  standing  bending  forwards,  PA,  reach  grasp 
standing  knee  flexion  and  extension,  PA,  &c. 

(5)  Hacking  of  the  tvhole  lateral  aspect  of  the  body. — The 
patient  assumes  side  lying  position.  The  hacking  is  administered 
over  the  posterior  scapular  region,  axilla  and  external  aspect  of 
the  trunk  and  leg  on  the  side  that  lies  uppermost.  This  may  be 
called  side  length  hacking. 

(6)  Hacking  of  the  lateral  aspect  of  the  legs. — The  patient 
assumes  side  lying  position.  The  hacking  is  administered  on  the 
lateral  aspect  of  the  uppermost  leg  from  the  crest  of  the  ilium 
down  to  the  ankle.     This  may  be  called  side  leg  hacking. 

(7)  Hacking  of  the  arms. — The  patient's  limb  is  placed  in 
yard  grasp  position.  The  hacking  is  administered  on  its  upper 
and  lower  surfaces  simultaneously. 

(8)  Hacking  over  the  spleen. — Is  administered  on  the  left  side 
on  the  ninth  to  eleventh  ribs  in  the  splenic  area,  with  the  patient 
in  left  side  span  standing  or  right  side  lying  position.  Georgii ' 
says  that  he  found  that  mere  percussion  of  the  spleen  sometimes 
caused  diminution  in  its  size.  If  this  be  so  hacking  should  have 
a  similar  effect,  but  greater  in  proportion  as  it  is  a  more  powerful 
manipulation.  The  reduction  in  size  is  probably  due  to  stimu- 
lation of  the  nonstriped  muscular  fibres,  causing  them  to  con- 
tract, just  as  in  the  case  of  hacking  and  clapping  over  the  heart 
(p.  203). 

(9)  Hacking  over  the  liver. — Is  administered  over  the  fifth  to 
tenth  ribs  laterally  on  the  right  side,  with  the  patient  in  right 
side  span  standing  or  left  side  lying  position. 

(10)  Hacking  over  the  kidneys. — Is  comprised  in  the  mani- 
pulation on  the  lumbar  region. 

(11)  Hacking  on  the  anterior  surface  of  the  abdomen. — Is 
rarely  resorted  to,  being  very  severe  ;  it  is  advantageously  re- 
placed by  other  manipulations.  However,  many  continental 
books  recommend  it. 

(12)  Hacking  over  the  heart. — May  be  administered  by  itself; 
more  usually  chest  clapping  is  substituted  for  it  (p.  203). 

'  "  Kinetic  Jottings,"  1880,  p.  97. 


202    ELEMEXTS  OF  KELLGREN'S  MANUAL  TREATMENT 

(J 3)  Hacking  on  the  head. — Was  at  one  time  used  by  Swedish 
g3'mnasts  ;  personally,  I  prefer  head  vibration  and  head  nerve 
frictions.  A  modified  kind  of  hacking  with  the  finger-tips  is 
advocated  by  Wide  '  ;  this  manipulation,  however,  I  regard  as 
of  extremely  little  value. 

(14)  Hacking  over  jnuscles  that  are  rheumatic  or  chronically 
inflamed  is  useful  in  diminishing  pain,  stiffness,  &c.,  and  breaking 
up  the  inflammatory  products. 

(15)  Hacking  over  suhctitaneous  effusions. — May  be  sometimes 
used  in  order  to  assist  in  their  absorption. 

II. — Clapping. 

This  is  chiefly  used  in  the  form  of  chest  clapping,  i.e.  : — 

Heave  Grasp  Standing  Chest  Clapping,  PP. 

The  assistant  stands  in  front  of  the  patient  and  passes  his 
arms  round  the  latter's  chest,  so  that  his  hands  lie  over  the  supra- 
scapular regions  with  their  palms  looking  directly  forwards 
(towards  himself),  his  forearms  being  thus  completely  supinated. 
Then,  with  loose  elbows,  wrist  and  finger-joints,  he  administers  a 
series  of  short  sharp  strokes,  first  over  the  suprascapular  and 
scapular  regions,  then  continuing  vertically  downwards  until  the 
lowest  parts  of  the  lungs  are  reached.  ,  Graduall}-  pronating  his 
forearms  as  they  travel,  he  continues  the  clappings  round  the 
sides  of  the  thorax  over  the  lower  ribs;  and  last  of  all,  with  his 
forearms  completely  pronated,  he  similarly  works  up  the  front  of 
the  chest  to  above  the  clavicle  (fig.  79).  With  female  patients 
the  clappings  should  be  given  nearer  to  the  sternum  while  pass- 
ing up  the  front  of  the  chest,  in  order  to  avoid  the  mammary 
glands. 

Effect  on  the  lungs. — The  lungs  are  stimulated,  expectoration 
is  facilitated,  and  respiration  after  the  close  is  freer  and  deeper. 
Part  of  this  is  due  to  the  propagated  vibration  from  the  manipula- 
tion, and  I  think  I  am  also  right  in  saying  that  a  good  deal  of  the 
effect  is  due  to  stimulation  of  the  sensory  nerves  of  the  thorax, 
chiefly  those  of  the  skin  ;  perhaps  the  afferent  fibres  of  the  vagus 

'  "  Haudbok  i  Medicinsk  Gymnastik,"  1895,  pp.  38,  &c.  ;  "  Handbook  of  Medical 
Gymuastics,"  1899,  pp.  37,  &c.  ;  "  Handbok  i  Medicinsk  och  Ortopedisk  Gymnastik," 
1902,  pp.  36,  &c.  ;  "  Handbook  of  Medical  and  Orthopa'dic  Gymnastics,"  1903, 
pp.  45,  &c. 


GYMNASTIC  MOVEMENTS  203 

are  also  involved.  Whether  or  not  chest  clapping  causes  contrac- 
tion in  the  nonstriped  muscular  fibres  of  the  trachea,  bronchi,  &c., 
and  whether  it  does  or  does  not  increase  the  ciliary  movement 
are  matters  for  future  investigation. 

Effect  on  the  heart. — The  heart  is  stimulated  as  in  the  case  of 
heart  vibration  (p.  190),  only  to  a  greater  extent.  The  physio- 
logical reasons  for  this  are  probably  as  follows  : — 

(1)  There  is  a  nervous  element  involved  similar  to  that 
described  under  heart  vibration. 

(2)  There  is  a  direct  effect  on  the  muscular  tissue  of  the  heart 
itself. 

{Cf.  Heitler.^     See  also  hacking  over  the  spleen,  p.  201). 

Clappings  may  be  administered  on  the  extremities ;  the 
principle  is  the  same  as  for  hacking.  The  effect,  however,  is 
more  superficial ;  the  cutaneous  nerves  and  vessels  in  particular 
are  stimulated. 

Clapping  of  the  soles  of  the  feet  is  useful  in  cases  of  partial  or 
total  anaesthesia,  which  so  readily  cause  difficulty  in  the  preserva- 
tion of  equilibrium.  "  The  greater  the  susceptibility  of  the  sole 
of  the  foot  the  safer  does  one  stand.  Vierordt  placed  on  the 
vertex  of  a  man's  head  a  fine  writing  style,  which  pointed  upwards, 
and  over  its  free  end  a  piece  of  smoked  paper  was  stretched 
horizontally.  When  the  man  was  standing  the  swayings  that 
ensued  in  his  head  were  depicted  in  the  form  of  a  closed  curve, 
whose  diameter  became  smaller  the  steadier  the  man  stood.  If 
by  means  of  placing  the  feet  in  ice-cold  water,  or  inunction 
thereof  with  chloroform,  their  susceptibility  was  diminished,  the 
swayings  increased,  and  the  diameter  of  the  curves  described 
became  proportionately  larger  "'  (J.  Munk^). 

III. — Beating. 

Reach  Grasp  Step   Standing  Knee  Flexion  and  Extension,  PA, 
Sacral  Beating,  PP. 

While  the  patient  executes  the  active  part  of  the  above  move- 
ment, the  assistant  administers  the  beatings  as  follows :  during 

'  "  Uber  akute  Herzerweiterung,"  in  Wien.  Med.  Woclienschr.,  1882,  No.  23;  and 
"  tjber  die  Wirkung  thermischer  und  mechanisclier  Einfliisse  au£  der  Tonus  des 
Herzmuskels  "  in  Ceniralbl.  f.  die  ges.  Therapie,  1894. 

■'  "  Physiologie  des  Menschen  und  der  Siiugethiere,"  1892,  p.  361  (translated). 


204   ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

flexion  of  the  knee,  over  the  upper  part  of  the  sacrum  and  upper 
and  inner  parts  of  the  gluteal  regions;  during  extension,  down  the 
sacrum  so  that  the  final  ones  take  place  over  the  coccyx  just  as 
complete  extension  is  attained  (fig.  80). 

Sacral  beating  can  also  be  administered  with  the  patient  in 
forwards  lying  position. 

The  sacral  nerves,  gluteal  regions,  rectum,  and  pelvic  organs ' 
are  stimulated ;  the  last-mentioned  are  affected  in  part  directly 
through  propagation  of  the  vibrations  set  up  by  the  beatings,  and 
in  part  indirectly  through  reflex  action  from  the  sacral  nerves. 

Beating  down  the  spinal  column  in  the  middle  line  posteriorly 
may  be  used  in  spinal  cord  conditions.  The  results  are  the  same 
as  from  back  hacking,  although  more  marked.  It  is  a  curious 
fact  that,  although  one  bad  concussion  can  have  such  a  destructive 
effect  on  the  spinal  marrow,  yet  a  number  of  very  minute  ones, 
such  as  are  brought  about  by  these  manipulations,  have  the 
opposite  effect  (cf.  Georgii"). 

Beatings  can  also  be  made  use  of  over  various  groups  of 
muscles,  oedematous  parts  of  the  limbs,  &c.,  as  desired. 


'  Cf.  Liljevalch,  "Rapport  ofver  Venei-iska  Sjakdoms  Forhallanden  i  Kongeliga 
Allmanna  Garnisons  Sjukhuset  i  Stockholm  under  ar  1839";  also  Thure  Brandt's 
various  works  (a  list  is  given  on  p.  234). 

-"  Kinetic  Jottings,"  1880,  p.  128. 


GYMNASTIC  MOVEMENTS 


STROKING. 


The  assistant's  hand  is  placed  so  that  the  palmar  aspect  of  two 
or  more  fingers,  with  or  without  the  thumb,  and  with  or  without 
the  palm  itself,  lies  in  contact  with  the  part  to  be  manipulated. 
The  hand  is  then  slowly  made  to  travel  over  the  skin  of  the  part 
{i.e.,  the  hand  and  skin  do  not  move  in  unison  over  the  underlying 
structures,  as  is  done  in  kneading,  p.  207) ;  this  is  done,  unless 
contra-indicated,  in  a  centripetal  direction,  a  certain  amount  of 
pressure  being  exercised  simultaneously.  The  hand  is  then  lifted 
off  and  brought  back  to  its  original  position,  whereupon  the 
manipulation  is  repeated  several  times,  the  whole  operation  lasting 
from  half  a  minute  to  two  or  three  minutes. 

Pure  stroking  movements  are  not  employed  very  much  by 
Henrik  Kellgren,  who  as  a  general  rule  replaces  them  by 
vibratory  strokings  and  other  manipulations.  They  may,  how- 
ever, be  employed  once  or  twice  in  succession  to  act  as  a  sedative 
on  the  nerves  of  the  skin  after  clappings  or  other  nerve-stimulating 
manipulations. 

Such  vibratory  strokings  should  be  administered  centripetallij 
when  it  is  desired  to  further  absorption  by  the  veins  and  lym- 
phatics, but  centrifugally  when  dealing  with  cases  such  as 
lymphangitis  from  wound  infection,  &c.,  when  it  is  desired  on  no 
account  to  promote  absorption,  but  instead  to  prevent  it,  and  also 
to  bring  the  toxic  matters  back  to  their  point  of  entrance  and 
thus  remove  them  (see  lymphangitis). 

Pure  stroking  movements  are,  for  all  practical  purposes, 
equally  effective  when  a  linen  garment  is  interposed  between  the 
assistant's  fingers  and  the  skin  of  tlie  patient ;  this  applies  also  to 
vibratory  strokings  administered  centripetally.  The  point  will  be 
further  considered  under  kneadings  (see  p.  212).  Vibratory  strok- 
ings administered  centrifugally  should,  however,  as  a  rule  be 
given  on  the  bare  skin,  as  in  order  to  produce  the  due  effect  it 
is.  necessary  to  follow  the  exact  route  of  the  red  lines  that  mark 
out  the  affected  lymphatic  vessels. 

Physiological  effect  of  strokings  and  vibratory  strokings  :  — 


2o6    ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

(1)  Given  centripetally  : — 

(a)  The  venous  flow  is  hastened. 

(b)  The  lymphatic  return  is  promoted,  and  effusions,  kc,  are 
absorbed. 

(c)  The  cutaneous  nerves  are  affected  ;  they  are  soothed  by 
hght  strokings,  somewhat  stimulated  by  stronger  ones,  and 
stimulated  most  of  all  by  vibratory  strokings. 

(<Z)  The  underlying  muscles  are  directly  stimulated  to  a  slight 
extent. 

(e)  Occasionally  reflex  effects  through  the  sensory  nerves  are 
obtained. 

The  greater  the  amount  of  pressure  that  is  applied  the  deeper 
will  the  effect  of  the  manipulation  penetrate. 

(2)  Given  centrifugally.     See  p.  205. 


GYMNASTIC  MOVEMENTS  207 


KNEADING. 


This  manipulatiou  is  directed  especially  at  subcutaneous 
tissues,  such  as  muscles,  tendons,  joints,  &c.,  and,  in  the  case  of 
the  abdomen,  the  internal  organs,  although  the  intervening  skin 
is  naturally  to  some  extent  also  affected. 

There  is,  perhaps,  in  the  whole  range  of  the  manual  treatment 
no  class  of  manipulations  more  difficult  to  describe  than  that  of 
kneadings  ;  it  will  be  best  to  consider  the  more  important  methods 
separately  instead  of  framing  any  generalisation.  The  following 
"varieties  will  be  described  : — 

(1)  Of  muscles. 

(a)  When  a  definite  lesion  is  present  in  a  particular  muscle  or 
part  thereof. 

{b)  When  no  such  lesion  is  present,  and  it  is  only  desired  to 
stimulate  rapidly  all  the  muscles  of  a  limb. 

(2)  Of  joints. 

(3)  Of  effusions. 

(4)  Of  the  abdomen. 

(1)  Kneading  of  Muscles. 

During  this  manipulation  the  muscles  must  be  kept  passive 
and  relaxed,  not  stretched. 

Cases  requiring  kneading  of  a  definite  lesion  in  a  muscle. — The 
assistant's  fingers  and  thumb  are  kept  as  far  as  possible  extended 
in  their  interphalangeal  joints,  although  as  loose  as  is  compatible 
with  the  proper  elastic  execution  of  the  movement.  The  method 
of  application  depends  on  the  situation  of  the  muscle  under  treat- 
ment. Should  more  than  one  surface  of  the  patient's  muscle  be 
accessible,  the  assistant  grasps  that  muscle  between  his  fingers 
and  thumb  ;  the  point  of  application  of  his  grasp  being,  how- 
ever, not  over  the  actual  part  to  be  kneaded,  but  a  little  above 
it.  Then,  the  skin  of  the  patient  moving  in  unison  with  them, 
the  assistant  moves  his  fingers  and  thumb  backwards  until  they 
lie  over  the  part  in  question.  If  the  condition  laid  down  be 
not  complied  with  the  range  of  the  movement  is  diminished. 
The  patient's  skin  moving  constantly  in  unison  with  them,  the 


2o8  ELEMENTS  OF  KELLGREN'S    MANUAL    TREATMENT 

assistant's  fingers  and  thumb  are  carried  forwards  in  a  centripetal 
direction,'  meanwhile  applying  pressure  towards  one  another  and 
against  the  underlymg  structures  until  the  patient's  skin  is  on  the 
stretch,  when  the  movement  forwards  should  be  arrested.  Then 
the  assistant's  fingers  and  thumb,  relaxing  their  pressure,  pass 
back  again  to  their  original  position.  The  direction  of  the  move- 
ment should  not  be  simply  forwards  and  backwards,  but  more  in 
the  form  of  an  ellipse,  so  that  the  patient's  muscle  is  moved 
alternately  to  one  side  when  the  fingers  and  thumb  proceed 
forwards,  and  to  the  other  side  during  the  reverse  process.  The 
manipulations  should  be  repeated  uninterruptedly  for  a  minute  or 
two. 

Should  only  one  surface  of  a  patient's  muscles  be  accessible, 
the  assistant  uses  only  the  fingers  (or  else  the  thumb),  placed 
over  the  part  to  be  manipulated.  The  kneading  takes  place  as 
before,  with  pressure  e.xercised  towards  the  underlying  structures. 
The  manipulation  can  be  administered  with  one  or  both  hands. 
In  the  latter  case,  the  hands  are  placed  at  a  different  level,  and 
both  alternately  execute  the  same  movement  as  did  the  one  hand ; 
or  else  the  fingers  of  the  one  hand  can  be  used  to  replace  the 
thumb  of  the  other.  In  the  former  case  the  second  hand  is  used 
to  steady  the  part  manipulated. 

Cases  requiring  rapid  stimulation  of  all  the  muscles  of  an- 
arm  or  leg. — The  assistant  uses  both  hands,  and  beginning  at  the 
patient's  hand  or  foot,  on  opposite  sides  of  the  limb,  executes 
with  each  hand  the  movement  as  first  described,  with  this 
exception,  that  after  each  individual  kneading  his  hands  move  to 
a  higher  level  before  repeating  it,  thus  passing  rapidly  up  the 
limb.  He  may  also  execute  the  manipulation  beginning  at  the 
trunk  and  passing  down  the  limb,  his  hands  moving  to  a  lower 
level  after  each  individual  kneading,  although  the  direction  of 
each  such  manipulation  is  centripetal  as  before. 

In  some  cases  kneadings  may  be  given  centrifugally ;  the 
reasons  for  doing  so  are  the  same  as  those  mentioned  under 
vibratory  strokings  (p.  205).  The  modus  operandi  is  the  same  as 
for  centripetal  kneadings,  excepting  that  the  direction  of  the 
movement  is  reversed,  i.e.,  the  hand  begins  below  the  muscle  to 
be  manipulated,  is  carried  centripetally  until  it  lies  over  it,  and 
the  actual  kneading  given  centrifugally. 

'  See  below  for  exceptions  to  this  rule. 


GYMNASTIC  MOVEMENTS  209 

(2)  Kneadings  of  Joints,  Bones,  &c. 

These  are  executed  in  the  same  manner  as  the  kneadings  of 
those  muscles  which  are  only  accessible  on  one  surface. 

(3)  Kneadings  of  Effusions. 

The  method  adopted  depends  upon  the  site  of  the  effusion  : — 

(a)  Effusions  mto  the  peritoneal  cavity. — Are  treated  by  means 
of  stomach  exercise  (see  p.  227). 

(6)  Effusions  into  a  synovial  cavity  of  a  joint. — Are  treated  by 
kneading  of  the  same  type  as  described  under  (2)  above. 

(c)  Effusions  into  tendon  sheaths,  and  arising  from  dislocation, 
fracture,  &c. — Are  treated  by  kneading  of  the  same  type  as  is 
used  for  muscles  of  which  only  one  surface  is  accessible. 

Kneadings  of  such  effusions  are  usually  continued  for  a  longer 
time  than  those  of  muscles.  For  whatever  reason  kneadings  are 
made  use  of,  they  should,  whenever  possible,  be  supplemented 
by  passive  movements  at  joints,  duplicate  exercises  and  nerve 
frictions,  &c. 

(4)  Kneading  of  the  Abdomen. 
See  stomach  exercise  (p.  227). 
Physiological  Effects  of  Kneadings  : — 

(1)  Kneading  of  Muscles, 
(a)  given  centripetally. 
I. — Local  effects. 

(a)  The  venous  flow  is  accelerated. 

{b)  The  lymphatic  circulation  is  furthered. 

(c)  A  preliminary  vaso-constriction  takes  place,  lasting  only 

a  very  short  time  ;  this  is  followed  by  vaso-dilatation, 
an  increase  of  arterial  blood  being  supplied  to  the 
muscles. 

(d)  The  tone  of  the  muscular  fibres  is  improved. 

(e)  The  nerves  of  the  muscles   are  stimulated ;    this  is,  I 

believe,  a  more  important   factor  than   has  hitherto 
been  allowed. 
(/)  Pathological  products  are  broken  down  and  absorbed. 
11. — General  effects. 

(a)  The  blood  pressure  is  diminished,  and  the  heart  relieved 

of  some  of  its  work. 
{b)  The  metabolism  as  a  whole  is  increased. 
U 


2IO  ELEMENTS    OF   KELLGREN'S  MANUAL   TREATMENT 

(These  general  effects  only  arise  if  the  kneading  manipulation 
be  executed  over  a  large  area.) 

(b)  given  centuifugallv.     See  vibratory  strokings,  p.  205. 

(2)  Kneading  of  Joints. 
The  ligaments  and  neighbouring  muscles  and  tendons  are 
stimulated ;  at  the  same  time  that  vaso-dilatation  occurs  in 
these  structures  the  lymphatic  and  venous  return  is  promoted. 
The  fluid  of  chronic  synovitis  in  the  joint  will  tend  to  be  absorbed 
and  thickenings  of  the  synovial  membrane  itself  will  be  removed. 

(8)  Kneading  of  Effusions. 
The  effused  matter  is  more  quickly  absorbed. 

Definition  of  "  Massage,"  and  some  Notes  on  the  Introdnction  of 
Metzgers  Methods  into  Ling's  System. 

To  no  term  in  gymnastic  literature  have  there  been  attached 
in  the  course  of  time  so  many  different  meanings  as  to  the  term 
"massage."  Some  authors  denote  by  it  all  exercises,  whether 
active  or  passive,  that  exist  in  connection  with  medical  gym- 
nastics ;  others  have  attempted  to  draw  a  hard  and  fast  line 
between  massage  and  medical  gymnastics,  as  if  between  things 
definitely  dissimilar  ;  many  take  massage  to  denote  "  efifleurage," 
"  petrissage,"  "  massage  a  friction,"  and  "  tapotement,"  according 
to  Metzger's  methods ;  and  there  exist  compromises  between 
these  different  standpoints  of  innumerable  variety. 

For  myself  I  consider  that  the  word  "massage"  should  be 
restricted  to  denote  merely  Metzger's  "  effleurage,"  "petrissage," 
and  "massage  a  friction." 

Although   P.  H.  Ling,'  Neumann,-  Eothstein,^  Eoth,'*  have 

described  kneadings    of   muscles,    none   of  them   use   the    word 

"massage"    in   their   writings.      In   1873  two   Swedish  medical 

men,  Berghmann  and  Helleday,  visited  Metzger  in  Amsterdam, 

learnt   his  methods^  and   made   efforts    to  introduce  them  into 

'  "  Gymnastikens  Allmanna  Grunder,"  1866,  p.  582. 
=  "Die  Heilgymnastik,"  1852,  pp.  284-287. 
•'"Die  Gymuastiscben  Eustiibuugen,"  1861,  pp.  93,  &c. 
'"  Handbook  of  the  Movement  Cure,"  1866,  pp.  212-214. 

'Their  description  o£  these  methods  is  to  be  found  under  the  title  of  "  Auteck- 
ningar  om  Massage,"  in  Nordiskt  Medicinskt  Arcliia,  1873,  vol.  v.,  part  1,  No.  7. 


GYMNASTIC  MOVEMENTS  211 

Sweden.  Although  Metzger's  manipulations  were  inferior  to 
Ling's,  they  have  gained  a  good  deal  of  ground  in  Sweden  during 
the  last  few  years,  although  not  without  a  good  deal  of  opposition 
from  various  quarters.  The  differences  between  the  two  methods, 
the  history  of  the  term  massage,  and  its  introduction  into  Ling's 
system  have  been  discussed  by  Curman,'  Hartelius,-  Georgii,' 
Branting,*  and  others.  At  the  present  moment  in  Sweden, 
Metzger's  methods  are  advocated  by  Wide  ' ;  and  massage  manipu- 
lations have,  I  regret  to  say,  come  so  much  to  the  fore  that  they 
have  in  many  cases  entirely  superseded  other  movements,  both 
active  and  passive,  of  a  more  beneficial  nature. 

The  differences  between  Henrik  Kellgren's  kneading,  and 
Metzger's  petrissage  ("  massage '")  and  allied  methods  are  as 
follows : — 

(1)  The  fat  (vaseline,  tire.)  used  in  massage  renders  the  move- 
ment one  of  the  masseur's  fingers  over  the  skin  ;  thus  the  deep 
lying  structures  are  much  less  likely  to  be  affected.  In  the 
Kellgren  method  the  assistant's  fingers  and  the  skin  of  the  patient 
move  as  one  over  the  underlying  structures,  which  are  thus  affected 
to  a  far  greater  extent. 

(2)  The  fat  used  in  massage  prevents  skin  secretions  by 
clogging  the  orifices  of  the  sebaceous  and  sweat  glands.  This 
is  especially  apt  to  produce  unpleasant  effects,  because  any  form 
of  friction  or  massage  of  the  skin  greatly  increases  the  insensible 
perspiration.^  Often  the  so-called  "massage  eruptions"  arise, 
and  the  treatment  has  to  be  stopped  until  these  have  passed 
away. 

(3)  Massage  is  given  with  more  violence  and  easily  causes 
hypersemia  of  the  skin,  actual  soreness,  or  even  rupture  of  capil- 
laries.   "  A  great  drawback  to  continuing  massage  is  the  wounding 

'  "  Om  Massage  eller  Manipulationers  Anvaudande  for  Hygieuiskt  och  Thera- 
peutiskt  .\ndamal,"  in  Hygeia,  1S73,  April,  pp.  222-238. 

-  "  Historik  om  den  s.k.  Massagen,"  in  Tidskrift  i  Gymnastik,  1874,  part  2, 
pp.  49,  &c.  ;  see  also  "  Om  Sjukgymnastiken  vid  Gymnastiska  Central  lustitutet 
mider  ar  1863,"  1864,  p.  8  ;  "  Gymnastiska  lakttagelser,"  1865,  pp.  37,  &a. 

■'  "  Kinetic  Jottings,"  1880,  pp.  180-186. 

'"Efterlemnade  Skrifter,"  1882,  pp.  184,  185. 

^  "Handbok  i  Mediciusk  Gymnastik,"  1895,  pp.  145,  &c.  ;  "  Handbook  of  Medical 
Gymnastics,"  1899,  pp.  145,  &c.  ;  "Handbok  i  Medicinsk  och  Ortopedisk  Gym- 
nastik," 1902,  pp.  136,  &o.;  "  Handbook  of  Medical  and  Orthopaedic  Gymnastics," 
1903,  pp.  153,  &c. 

'Weyrich,  "Die  Unmerklicbe  Wasserverdunatung  der  menschlichen  Haut," 
1862,  p.  206,  et  seq. 


212  ELEMENTS   OF   KELLGREN'S    MANUAL   TREATMENT 

of  the  skill"  (Hoffa).'  In  such  a  case,  of  course,  the  treatment 
has  to  be  stopped  for  some  days  on  account  of  the  pain  that 
would  be  caused  were  the  manipulation  to  be  continued  regularly. 
It  is  for  this  reason  that,  it  being  impossible  to  give  massage 
to  recent  sprains,  dislocations,  &c.,  the  so  called  "  einleitungsmas- 
sage  "-  has  been  advocated.  This  takes  place  around  the  part  but 
not  on  it,  and  in  consequence  much  valuable  time  is  lost,  as  any 
exudation,  &c.,is  allowed  to  accumulate  and  organise. 

(4)  Massage  is  given  over  a  much  longer  time  ;  each  seance 
often  lasts  from  half  an  hour  to  an  hour.  This  is  quite  unneces- 
sary, as  active  and  passive  movements  at  joints  produce  the 
desired  result  much  more  quickly  and  efficaciously. 

(5)  Kneadings,  according  to  Kellgren's  method,  are  always 
executed  (unless  it  be  specially  contra-indicated)  not  on  the  bare 
skin  like  massage,  but  with  ordinary  thin  underclothing,  prefer- 
ably linen,  between  the  skin  of  the  patient  and  the  assistant's 
fingers.  This  is  in  order  to  give  steadiness  to  the  manipu- 
lation, to  prevent  hyperfemia  arising  in  the  skin  and  to  prevent 
the  unpleasantness  of  the  contact  of  two  skin  surfaces. 

(6)  Some  authors  recommend  first  stretching  the  muscles  to 
be  massaged ;  this  proceeding  is,  for  example,  frequently  advo- 
cated in  connection  with  massage  for  the  gluteus  maximus. 
When  administering  kneadings  according  to  Kellgren's  method 
the  muscles  to  be  manipulated  should  be  relaxed  (as  already 
stated),  because  otherwise  the  effect  of  the  manipulations  pene- 
trates far  less  deeply. 

Space  does  not  permit  me  to  go  into  details  concerning  the 
chief  experiments  on  the  physiological  phenomena  which  result 
from  various  forms  of  massage.  Lists  of  the  literature  can  be 
found  in — 

(1)  Beibmayr,  "Die  Massage  und  Ihre  Verwerthung  in  den 
verschiedenen  Disciplinen  der  Praktischen  Medicin,"  1893. 

(2)  Kleen,  "  Handbok  i  Massage,"  1894. 

(3)  A.  Bum,  "  Mechanotherapie,"  in  Enlenburg's  "  Encyclo- 
padie,"  1897. 

(4)  A.  Bum,  "  Handbuch  der  Massage  und  Heilgymnastik," 
1901. 

'"Teoknik   der   Massage,"    1897,   p.   15;    aud  "  Kinesitherapie,"   1898,  p.   490 
(translated.) 

"See  Reibmayr,  "  Die  Technik  der  Massage,"  1898,  p.  5,  et  seq. 


GYMNASTIC  MOVEMENTS  213 


PRESSING. 

Nerve  pressings  such  as  are  made  use  of  in  Ling's  system 
have  been  referred  to  already  (pp.  145,  &c.). 

Pressure  on  arteries,  otherwise  than  for  the  purpose  of  arrest- 
ing hsemorrhage  from  cut  vessels,  was  formerly  employed  at  the 
G.  C.  I.,  and  is  mentioned  in  the  writings  of  P.  H.  Ling,' 
Georgii,-  and  Hj.  Ling/  Pressure  on  the  abdominal  aorta  has 
been  employed  by  Branting  and  Liedbeck  to  check  hsemorrhage, 
post-partum  or  otherwise,  from  the  uterus  (Georgii*). 

Pressure  on  veins  was  formerly  employed  by  the  Ling  school, 
and  is  mentioned  in  the  works  of  P.  H.  Ling,^  Branting,'^ 
Neumann,'  Eothstein,*  Eoth,''  Hj.  Ling,^"  and  Georgii".  These 
manipulations  seem,  however,  in  later  times  to  have  fallen  into 
disuse.  Hartelius''  makes  no  mention  of  them  in  his  handbook, 
and  similarly  Wide  does  not  refer  to  them  in  his  handbooks. 

They  are  excellently  typified  by  bilateral  jugular  vein  com- 
pression, which  will  often  cure  rapidly  a  case  of  fainting  from 
anaemia  cerebri.  I  have  known  this  result  to  be  obtained  when 
even  cervical  nerve  frictions  (see  p.  162)  have  failed. 

Pressing  downwards,  forwards,  and  backwards  are  terms  used 
in  connection  with  some  leg  and  arm  movements.  These  have 
already  been  described. 


'  "  Gymnastikens  Allmanna  Grusder  "  (1834),  1840,  p.  160. 

-"Kinesith^rapie,"  1847,  pp.  51,  71;  "Kinetic  Jottings,"  1880,  pp.  55,  &o., 
89,  106,  &c. 

'In  Bi-auting's  "  Efterlemnade  Sljrifter,"  1882,  p.  svi. 

'"Kinesith^rapie,"  1847,  p.  51 ;  "Kinetic  Jottings,"  1880,  p.  89. 

■'  "  Gymnastikens  Allmanna  Grunder,"  1866,  pp.  584,  &o. 

•^Address  to  the  graduates  of  the  G.  C.  I.  on  April  8,  1848,  and  gymnastic 
prescriptions  in  "  Efterlemnade  Skrifter,"  1882. 

■"Die  Heilgymnastik,"  1852,  pp.  208,  &c.  ;  "  Lehrbuch  der  Leibesiibungen," 
1856,  p.  265. 

""Die  Gymnastik  nach  dem  System  des  Schwedischen  Gymnasiarchen  P.  H. 
Ling,"  1847,  p.  67. 

' "  Handbook  of  the  Movement  Cure,"  1856,  pp.  175,  &c. 

""'Porkortad  Ofversigt  af  Allmiin  Rorelselara,"  1880,  pp.  24,  60,  &c.  ;  Brant- 
ing's  "  Efterlemnade  Skrifter,"  1882,  pp.  xsiv. ,  &c. 

"  "  Kinesitherapie,"  1847,  pp.  54,  &c. ;  "  Kinetic  Jottings,"  1880,  pp.  67,  68. 

'-"Larobok  i  Sjukgymnastik,"  1870,  1883,  1892. 


214  ELEMENTS  OF  KELLGREN'S    MANUAL    TREATMENT 


VARIOUS  OTHER  EXERCISES  WHICH  DO  NOT  FALL 
UNDER  ANY  OF  THE  PREVIOUS  HEADINGS. 

Standing  Vertebral  Column  Stretching,  AR  at  Patient's  Head. 

The  patient  assumes  the  standing  position  usually  with  his 
back  against  a  wall.  The  assistant  places  one  hand  lightly  over 
the  patient's  abdomen  in  order  to  steady  him,  and  the  other  over 
his  lambda.     The  patient  endeavours  to  stretch  upwards  {i.e.,  to 


make  himself  as  tall  as  possible  without  rising  on  his  toes)  and 
backwards,  the  assistant  resisting  by  drawing  in  the  opposite 
direction.  No  actual  movement  should  result,  the  assistant  taking 
care  that  the  opposing  forces  just  neutralise  each  other  (fig.  81). 


GYMNASTIC  MOVEMENTS  215 

This  exercise  powerfully  influences  the  extensor  muscles  of 
the  spinal  column,  and  is  an  excellent  corrective  for  curvatures 
of  the  latter. 

If  properly  executed,  its  effects  will  be  felt  most  markedly 
in  the  lumbar  region. 

Standing  Stretching  of  the  Calf  Muscles,  PA. 

The  patient,  keeping  his  heel  on  the  ground,  Hexes  one  foot  to 
about  30°  by  resting  it  on  an  inclined  plane  or  some  other  suitable 
support.  Keeping  the  knee  of  that  side  fully  extended,  he  then 
flexes  his  ankle  still  further,  simultaneously  moving  his  trunk 
forwards,  thus  extending  his  hip.  The  reverse  movement  is  then 
executed  (lig.  82). 


There  flrst  results  elongation  and  consequent  stimulation  of 
the  calf  muscles  (with  their  nerves,  vessels,  and  lymphatics) 
with  passive  shortening  of  the  anterior  tibial  muscles,  and  then 
the  reverse.  If  the  patient  fails  to  keep  his  knee  fully  extended 
the  exercise  loses  a  great  deal  of  its  effect,  as  in  that  case  the 
points  of  attachment  of  the  gastrocnemius  to  the  femur  and  os 
calcis  are  approximated. 

Stride  Sit  Kneeling  Raising,  AR. 

The  patient  assumes  the  initial  position  with  neck  firm,  his 
back  being  somewhat  arched  so  as  to  bring  the  pelvis  forwards. 


2i6   ELEMENTS    OF    KELLGREN'S    MANUAL    TREATMENT 

The  assistant  grasps  the  patient  round  the  elbows  as  in  drawing 
backwards  (p.  123).  The  patient  then  sits  down  on  his  lower  legs 
with  his  trunk  erect,  effecting  this  by  flexing  both  thighs  and 
knees,  and  by  straightening  the  back.  The  reverse  movement  is 
then  executed  with  resistance  applied  in  a  backward  and  down- 
ward direction  over  the  front  of  the  elbows  (fig.  83). 


The  extensors  of  the  knees,  thighs,  and  spinal  column  are 
exercised.  The  anterior  part  of  the  abdomen  is  alternately 
elongated  and  shortened,  and  thus  stimulated.  The  movement  is 
depletive  for  the  pelvis. 


Movements  of  the  Lower  Jaw. 

These  may  be  prescribed  for  affections  of  the  muscles  con- 
nected with  the  jaw,  or  for  stiffness  in  the  temporo-maxillary 
joints.  Thus  in  jaw  opening,  AE,  resistance  being  applied  in 
the  middle  line  underneath  the  mentum,  the  following  muscles 
are  called  into  action — digastric,  mylo-hyoid,  and  geniohyoid.  In 
jaw  closing,  AR.,  resistance  being  applied  in  the  middle  line  over 


GYMNASTIC  MOVEMENTS  217 

the  mental  process,  the  temporal,  masseter,  and  internal  pterygoid 
are  actively  contracted  ;  and  so  on. 

Movements  of  the  Face. 

Various  active  movements  may  be  prescribed  in  cases  of  facial 
paralysis,  such  as  endeavouring  to  smile,  to  close  the  eye,  to 
wrinkle  the  forehead,  &c. 

Various  movements  such  as  v^^alking,  slowly  sitting  down  on 
a  chair  and  getting  up  again,  standing  with  the  feet  together  (as 
in  testing  for  Eomberg's  symptom),  &c.,  may  be  prescribed  for 
patients  who  are  suffering  from  paralysis,  disorders  of  coordina- 
tion, stiffness  of  joints,  &c. 

Subdiaphragmatic   Suction. 

The  patient  is  placed  in  half-lying  position.  The  fingers  and 
thumb  of  the  assistant  are  placed  respectively  about  half  way 
between  the  umbilicus  and  xiphisternum  about  two  inches  from 
the  middle  line.  Applying  a  certain  amount  of  pressure  the 
fingers  and  thumb,  moving  as  one  with  the  skin  of  the  abdomen, 
are  moved  at  a  fairly  slow  rate  downwards,  and  then,  relaxing  the 
pressure,  are  brought  back  again  to  their  original  position.  The 
process  is  repeated  for  a  minute  or  so. 

This  exercise  is  very  useful  in  relieving  chronic  diaphragmatic 
spasm. 

The  following  three  manipulations  are  applied  to  the  head  : — 

(1)  Biparietal  Movement. 

The  assistant  stands  behind  the  patient  and  places  his  hands 
(lying  with  their  long  axes  horizontal)  so  that  the  palmar  aspect 
of  the  palms  and  fingers  lies  on  the  lateral  parts  of  the  vault  of 
the  patient's  skull,  as  in  fig.  84  ;  then,  the  patient's  scalp 
moving  as  one  with  them,  the  assistant  moves  his  hands  sharply 
upwards  and  lightly  downwards  alternately  several  times  in  rapid 
succession. 

The  flow  in  the  veins  and  lymphatics  will  be  promoted  from 
the  alternate  application  and  removal  of  pressure,  and  from  the 
alternate  elongation  and  shortening  of  the  vessels.  The  nerves  of 
the  scalp  will  be  stimulated. 


>iS    ELEMENTS   OF    KELLGREN'S    MANUAL    TREATMENT 


(2)  Bitemporal  Movement. 

The  assistant  stands  behind  the  patient  and  places  the 
respective  hypothenar  eminences  of  his  two  hands  on  the  two 
sides  of  the  patient's  skull  in  the  anterior  part  of  the  temporal 


fossa,  as  in  fig.  85.  He  then  applies  pressure  in  an  inward 
direction,  i.e.,  he  tries  to  approximate  his  hypothenar  eminences 
directly  towards  one  another.     While  doing  this  he  causes  his 


GYMNASTie  MOVEMENTS  219 

hands  to  vibrate,  simultaueously  performing  a  circumductory 
movement  with  them,  the  patient's  scalp  moving  continually 
with  his  fingers.  The  direction  of  the  7U0vement  is  negative 
as  seen  from  the  patient's  left,  and  the  circle  described  is  about 
one  inch  in  diameter. 

This  manipulation  is  of  great  use  in  dealing  with  congested  or 
hyperaemic  states  of  the  brain  and  increased  intracranial  pressure, 
but  the  precise  anatomical  and  physiological  reasons  for  the 
benefits  obtained  are  very  difficult  to  explain.^ 

(3)  Occipital  Suction  Movement. 

This  manipulation  is  frequently  administered  together  with 
head  vibration.  While  one  hand  of  the  assistant  performs  the 
vibration,  the  fingers  of  the  other  hand  are  placed  over  the 
patient's  head,  as  in  fig.  86,  p.  'I'll.  The  scalp  moving  with  them 
they  are  drawn  sharply  downwards  and  then  lightly  back  again, 
thus  accelerating  the  venous  (and  also  the  lymphatic)  flow  from 
the  connection  between  the  veins  of  the  scalp  and  the  sinuses  in 
the  scalp.  As  there  is  an  intimate  connection  between  the  vems 
of  the  scalp  and  the  sinuses  in  the  brain,  the  latter  can  be  afl:ected 
through  the  medium  of  the  former. 


'  Cf.  Hj.  Ling's  remarks  on  "  tumporaltryckning  "  in  Brantiug's  "  Efterlemnadc 
Skrifter,"1882,  p.  xxii.  The  popular  remedy  of  relieving  headache  by  pressure  on 
the  temples  is  well  known. 


220  ELEMENTS   OF   KELLGREN'S   MANUAL    TREATMENT 


SPECIAL  MANIPULATIONS  OF  VARIOUS  REGIONS 
AND  ORGANS. 

In  certain  cases  when  it  becomes  necessary  to  treat  specially 
a  particular  region  of  the  body  (such  as  the  head,  eyes,  arm,  &c.), 
sets  of  manipulations  are  often  executed  in  a  definite  order  so  as 
to  affect  in  a  given  succession  the  vessels,  nerves,  muscles,  &c.,  of 
the  part  in  question.  Such  sets  of  manipulations  are  conveniently 
referred  to  under  the  one  comprehensive  term  "  exercise  "  ;  thus 
the  term  "head  exercise "  denotes  a  definite  sequence  of  ma- 
nipulations. 

The  descriptions  which  follow  are  only  intended  to  outhne 
such  sequences.  The  assistant  must  not  adhere  slavishly  to  every 
detail,  but  must  use  intelligence  and  discrimination  in  varying 
the  scheme  to  suit  each  patient. 

(1)  Head. 

Sitting  Head  Exercise,  PP. 

There  are  two  distinct  types  of  head  exercise  in  common  use, 
between  which,  however,  no  hard  and  fast  line  can  be  drawn  ; 
the  exercise  actually  administered  may  be  of  a  kind  anywhere 
intermediate  between  the  two  types,  as  required.  In  complex 
cases  it  becomes  necessary  to  devise  a  new  modification  for  each 
patient. 

The  two  types  are  as  follows :  — 

(A)  For  cases  such  as  fevers  or  chronic  headache  from  hyper- 
aemia  cerebri,  where  it  is  desired  to  soothe  and  reduce  cerebral 
excitement.     The  assistant 

(1)  Performs  head  lifting  ; 

(2)  Vibrates  or  works  on  those  parts  of  the  head  demanding 
special  attention ; 

(3)  Gives  nerve  frictions,  general,  and  also  local  if  required  ; 

(4)  Repeats  head  lifting. 

The  following  are  the  commonest  forms  of  this  type  of  head 
exercise: — 


GYMNASTIC  MOVEMENTS 


One  hand  administers 

Double   supraorbital  nerve  friction  or, 

vibration,  or  frontal  vibration. 
Coronal  suture  vibration.  ,'■ 

Sagittal  suture  vibration. 
Double  parietal  vibration.  ' 


The  other  hand  administers 

I  Double  great  occipital  nerve  friction. 
J  Double  second  cervical  nerve  friction. 
I  Occipital  suction  movement. 
>  Occipital  vibration. 


Fig.  86  represents  coronal  suture  vibration,  with  occipital 
suction  movement ;  fig.  87  represents  frontal  vibration  with  double 
upper  cervical  nerve  friction. 


In  cases  of  fever  it  is  generally  possible  by  means  of  the  above 
type  of  exercise  to  cause  a  hot  head  to  become  cool ;  and  in  some 
cases  an  actual  reduction  in  temperature  will  result,  as  can  be 
seen  by  comparing  thermometer  readings  (from  either  axilla  or 
rectum)  taken  just  before  and  after  the  manipulation.  In  cases 
of  hypersemia  or  congested  states  of  the  brain  not  accompanied  by 
fever,  amelioration  or  even  cure  may  be  effected  b}^  the  same 
means. 

(B)  For  cases  of  disseminated  cerebro-spinal  sclerosis,  general 
paralysis,  &c.  (a  much  more  stimulatory  exercise).     The  assistant — 

(1)   Performs  head  lifting  ; 


222  ELEMENTS   OF   KELLGREN'S    MANUAL   TREATMENT 

(■2)  Administers  strong  vibrations  with  one  hand  on  the 
sagittal  or  coronal  sutures,  while  the  other  hand  administers 
strong  frictions  on  the  great  occipital  nerves  ; 


(8)  Executes  biparietal  and  bitemporal  movements  ; 

(i)  Administers  strong  nerve  frictions  around  the  sides  of  the 
skull  (fig.  88),  and  in  the  line  of  the  superior  longitudinal  sinus  ; 
also  on  individual  nerves  if  required  ; 


GYMNASTIC  MOVEMENTS  223 

(b)  Administers  strong  cervical  nerve  frictions,  with  pressure 
vibration  on  the  sagittal  or  coronal  suture ; 
(6)  Repeats  head  lifting. 

The  first  of  the  above  two  types  is  generally  continued  for  a 
longer  interval  of  time  than  the  second,  for  which  two  to  five 
minutes  should  suffice. 


(2)  Throat. 

Sitting  Throat  Exercise,  PP. 

The  assistant — 

(1)  Performs  head  lifting  ; 

(2)  Keeping  the  patient's  head  erect  or  even  a  little  flexed 
forwards/  with  one  hand  either  steadies  the  head  or  administers 
cervical  nerve  frictions  (paying  particular  attention  to  the  second 
pair)  ;  and  with  the  other  vibrates  or  shakes  the  submaxillary 
region,  larynx,  trachea,  inflamed  glands,  &c.,  in  whole  or  in  part 
according  to  the  nature  and  site  of  the  lesion  ; 

(3)  Administers  frictions  on  the  nerves  of  the  affected  part, 
especially  the  superior  and  inferior  laryngeal ; 

(J-)   Repeats  head  lifting. 

This  throat  exercise  can  be  administered  in  a  quiet  soothing 
manner,  or  energetically  to  be  more  stimulating,  according  to  the 
condition  of  the  patient. 

Many  continental  works  on  massage  and  gymnastics  ascribe 
to  Gerst  -  the  credit  of  having  been  the  first  to  use  local  manipula- 
tions for  the  throat.  This  is,  however,  quite  a  mistake.  Such 
manipulations  are  mentioned  in  the  1840  ^  edition  of  P.  H.  Ling's 
works ;  and  in  the  1866  *  edition  it  is  stated  that  "  the  (various) 
parts  of  the  throat  can  be  treated  by  stroking,  pressure,  or  shak- 
ing."    Branting '  in  1842  referred  to  a  local  throat  movement. 


'  If  the  head  is  beut  backwards,  the  omoliyoid  and  sternomastoid  compress  the 
iutenial  jugular  vein  and  thus  tend  to  cause  congestion  of  the  parts  mentioned 
in  (2) ;  see  page  74. 

-Gerst's  original  article  on  effleurage  of  the  throat  was  published  in  "  TJber 
deu  Therapeutisohen  Werth  der  Massage  "  in  1879. 

"'Gymnastikens  AUmanna  Grander"  (1834),  1840,  p.  160. 

*Ibid.,  1866,  p.  530. 

'  Address  to  the  Graduates  of  the  G.  C.  I.  on  April  1,  1842. 


224  ELEMENTS   OF   KELLGREN'S   MANUAL    TREATMENT 

(3)  Eye. 
Sitting  Eye  Exercise,  PP. 

The  assistant — 

(1)  Performs  head  hfting  ; 

(2)  Vibrates  the  eye  or  eyes  using  either  one  or  both  hands ; 

(8)  Administers  frictions  on  the  various  nerves  of  the  eye- 
lids and  orbit,  i.e.,  infraorbital,  supraorbital,  infra-  and  supra- 
trochlear, nasal,  and  the  areas  in  the  scalp  described  on  p.  158, 
first  and  second  cervical  sympathetic  ganglia,  &c. ; 

(4)  Administers  a  few  light  vibratory  strokings  on  the  upper 
lids  in  the  direction  of  the  venous  flow ; 

(5)  Repeats  head  lifting. 

A  head  exercise  may  be  added  if  symptoms  point  to  congestion 
or  other  morbid  states  of  that  part  on  which  the  eye  symptoms 
wholly  or  partly  depend. 

All  head,  throat  and  eye  exercises  given  for  conditions  depen- 
dent on  congestion  or  hyperaemia,  should  be  followed  by  deriva- 
tive movements,  especially  such  as  increase  the  venous  return  in 
the  internal  jugular  vein. 

I  have  frequently  seen  it  stated  that  the  treatment  of  eye 
disease  by  local  gymnastic  methods  was  originated  by  Donders' 
in  1872.  However,  the  priority  belongs  to  the  Ling  school, 
and  probably  Branting  was  the  first  to  use  such  manipula- 
tions in  this  connection  (Hj.  Ling-).  (Although  P.  H.  Ling^ 
refers  to  "  light  manipulations  over  the  eyebrows  "  for  head- 
ache, this  does  not  justify  the  statement  that  he  ever  undertook  the 
treatment  of  cases  of  eye  disease.)  Neumann  refers  to  eye  vibra- 
tion and  eye  diseases  in  18.52, ■*  1855,^  and  18.57,"  and  Melicher 
(a  pupil  of  Branting  and  Georgii)  treated  eye  disease  by  gymnastic 
methods  in  1852,"  1853,'  1854,^  1855,'°  1856  ('?),  1857,"  &c. 

'  Donder's  first  publication  is  in  Klinische  Monatsbliitter  far  Aiigeiiheilkunde, 
1872,  p.  302. 

-  Brantiag's  "  Efterlemuade  Skrifter,"  1882,  p.  xxvi. 

'  "  Gymnastikens  AUmauua  Grander  "  (1834),  1840,  p.  160. 

<  "  Die  Heilgymnastik,"  1852,  pp.  292,  379,  882. 

' "  Bericht  iiber  das  zweite  Jahr  des  Instituts  fiir  Heilgymnastik  in  Berlin," 
in  Athencpmn  fur  Rationelle  Gymnastik,  vol.  ii. ,  1855,  part  3,  p.  256. 

"  "  Therapie  der  Chronisohea  Kraukheiten,"  1857,  pp.  280,  &c. 

■  "  Erster  Bericht  iiber  das  Institut  fiir  Schwedisehe  Heilgymnastik  und  Orto- 
piedie,"  1853,  p.  5. 

"  "  Jahresbericlit  fiir  1858  iiber  das  erste  Institut  fiir  Schwedisehe  Heilgymnastik 
und  Ortopffidie  zu  Wein,"  1854,  p.  37. 

'  "  Jahresbericht  fiir  1854,"  &c.,  1855,  p.  21. 

'"  "  Jahresbericht  fiir  1855,"  &c.,  1856,  p.  31. 

"  "  Jahresbericht  fiir  1856  und  1857,"  &c.,  1858,  p.  38. 


GYMNASTIC  MOVEMENTS  225 

(4)  Ear. 
Sitting  Ear  Exercise,  PP. 

The  assistant — 

(1)  Performs  head  lifting  ; 

(2)  Administers  vibrations  or  shakinfjs  in  the  meatus  itself,  or 
of  the  meatus  through  the  tragus,  or  from  behind  through  the  root 
of  the  pinna ; 

(3)  Performs  shaking  of  the  whole  pinna  and  external  meatus  ; 

(4)  Administers  vibrations  or  shakings  over  the  mastoid 
process ; 

(5)  Administers  vibrations  or  frictions  on  the  posterior  auri- 
cular, great  auricular,  and  facial  nerves  ; 

(6)  If  necessary,  administers  vibrations  or  frictions  on  the 
glosso-pharyngeal  and  fifth  nerves,  and  on  the  second  cervical 
sympathetic  ganglia ; 

(7)  Executes  running  frictions  on  the  scalp  in  front  of,  above, 
and  behind  the  pinna  ; 

(8)  Treats  the  pharynx  if  necessary  ; 

(9)  Bepeats  head  lifting. 

Neumann'  refers  to  gymnastic  treatment  for  ear  diseases,  and 
Melicher  mentions  cases  treated  by  him  in  18.52,'^  1853,'^  1854,  ■* 
1855,5  1856,«  1857,'  &c. 

(5)  Upper  Extremity. 
Sitting  Arm  Exercise,  PP,  PA,  &c. 

(Or  PP,  PE,  AR,  if  duplicate  movements  are  included.) 

The  assistant — 

(1)  Rapidly  kneads  the  muscles  of  the  arm  as  a  whole,  with 
particular  attention  to  parts  specially  affected  ; 

(2)  Administers  finger  rolling  ;  kneading  of  any  affected  joint ; 

'  "  Lehrbuch    der    Leibesiibuugen,"    185G,    part    ii.,   p.    301;     "  Therapie    der 
Chrouischen  Krankheiten,"  1857,  pp.  287,  &c. 
-'  "  Erster  Bericht,"  Ac,  1853,  pp.  4,  5. 
»"  .Jahresbericht  fiir  1853,"  &c.,  1854,  pp.  3G,  37. 
'  "  Jahresbericht  fiir  1854,"  &e.,  1855,  pp.  20,  21. 
■'  "  Jahresbericht  fiir  1855,"  &c.,  1856,  pp.  30,  31. 
"  "  Jahresbericht  fiir  1856  und  1857,"  &c.,  1858,  pp.  37,  38. 

15 


226    ELEMENTS  OF  KELLGREN'S  MANUAL  TREATMENT 

movements  at  the  interphalangeal  and  luetacarpo-phalangeal  joints 
either  PP,  PA,  PR,  or  AR  ; 

(3)  Administers  hand  rolling  ;  kneading  of  wrist-joint ;  move- 
ments of  wrist-joint  either  PP,  PA,  PR,  or  AR  ; 

(4)  Performs  pronation  and  supination  either  PP,  PA,  PR, 
or  AR ; 

(5)  Administers  elbow-joint  kneading ;  flexion  and  extension 
of  that  joint  either  PP,  PA,  PR,  or  AR  ; 

(6)  Administers  shoulder-joint  kneading,  movements  of  that 
joint  either  PP,  PA,  PR,  or  AR  ; 

(7)  Executes  nerve  frictions,  general  or  local,  on  the  nerves 
supplj'ing  any  affected  joints,  or  paralysed,  &c.,  muscles  ; 

(8)  Performs  hacking  or  clapping  of  the  arm  as  a  whole  ; 

(9)  Performs  arm  traction  sideways,  PP. 

It  is,  of  course,  hardly  ever  necessary  to  carry  out  all  the 
above,  and  manipulations  specified  in  (2)  to  (6)  are  only  necessary 
in  cases  where  the  parts  particularly  referred  to  are  affected. 

(6)  Lower    Extremity. 

Half  lying  Leg  Exercise,  PP,  PA,  &c. 

(Or  PP,  PR,  AR,  if  duplicate  movements  are  included.) 

The  assistant — 

(1)  Rapidly  kneads  the  muscles  of  the  leg  as  a  whole,  witli 
particular  attention  to  parts  specially  affected  ; 

(2)  Performs  toe  rolling ;  kneading  of  any  affected  joint ; 
movements  of  the  various  joints  of  the  toes  either  PP,  PA, 
PR,  or  AR  ; 

(3)  Performs  foot  rolling  ;  kneading  of  any  affected  jonit  in 
the  tarsus  and  the  ankle  ;  movements  of  such  joints,  either  PP, 
PA,  PR,  or  AR  ; 

(4)  Performs  knee-joint  kneading;  movements  of  that  joint 
either  PP,  PA,  PR,  or  AR  ; 

(5)  Performs  hip-joint  kneading ;  movements  of  that  joint 
either  PP,  PA,  PR,  or  AR  ; 

(6)  Executes  nerve  frictions,  general  or  local,  on  the  nerves 
supplying  any  affected  joints,  or  paralj'sed,  &c.,  muscles ; 

(7)  Performs  hacking  or  clapping  of  the  leg  as  a  whole ; 

(8)  Performs  leg  traction,  PP. 


GYMNASTIC  MOVEMENTS  227 

(7)  Abdomen. 

(Exclusive  of  the  genital  organs). 

Half  lying  Stomach  Exercise,  PP. 

The  patient  assumes  neck  firm  half  lying  position.  The 
assistant  sits  at  the  patient's  right  side,  so  as  to  look  towards 
his  face,  as  in  fig.  89. 

The  right  hand  of  the  assistant  is  placed  on  the  front  of 
the  patient's  abdomen,  so  that  the  fingers  (which  are  somewhat 


separated)  lie  in  its  left  lumbar  region,  the  thumb  (which  is 
abducted)  in  its  right  lumbar  region,  and  the  palm  of  the  hand 
in  its  umbilical  and  hypogastric  regions. 

The  anterior  abdominal  wall  and  the  hand  of  the  assistant 
are  then  moved  as  one  over  the  underlying  structures.  The 
fingers  and  thumb  should  first  of  all  be  somewhat  flexed,  so  as 
to  close  on  the  middle  part  of  the  abdomen  where  the  small  intes- 
tines lie  ;  then  the  actual  movement  is  carried  out  in  the  line  of 
the  large  intestine  in  a  negative  direction  as  seen  from  the  front, 
i.e.,  in  the  direction  of  the  normal  onward  passage  of  the  fffical 
contents. 

The  thumb  has  to  apply  a  certain  amount  of  pressiu'e  and 
travel  over  the  ascending  colon  and  hepatic  flexure  to  the  com- 


22S   ELEMENTS   OF  KELLGREN'S   MANUAL   TREATMENT 

luencement  of  the  transverse  colon.  This  is  effected  b}' pronating 
the  forearm  somewhat,  moving  the  hand  upwards,  and  then,  when 
the  thumb  lies  in  the  right  hypochondrium,  moving  the  hand 
upwards  and  inwards,  adducting  the  thumb  at  the  same  time. 
The  fingers,  which  then  lie  on  the  transverse  colon,  take  up  the 
movement ;  they  apply  a  certain  amount  of  pressure  and  travel 
along  the  large  intestine  down  to  the  sigmoid  flexure.  The  fore- 
arm is  therefore  somewhat  supinated,  and  the  hand  travels  at 
first  outwards  and  downwards,  then  directly  downwards,  and, 
finally,  downwards  and  inwards ;  meanwhile  the  amount  of 
supination  is  gradually  increased,  and  the  fingers  are  gradually 
flexed  at  their  metacarpo-phalangeal  joints,  so  that  in  the  left  iliac 
fossa  they  lie  fairly  deep  down  in  the  sigmoid  flexure. 

During  the  movement  on  the  left  side  of  the  abdomen  the 
pressure  on  its  right  side  is  relaxed  through  the  increasing  supina- 
tion, and  the  thumb  is  thus  brought  lightly  down  into  the  right 
iliac  fossa.  The  movement  is  continued  by  the  forearm  being 
again  somewhat  pronated,  and  the  hand  moving  upwards  and 
outwards.  Thus  the  thumb  exerts  pressure  on  the  right  iliac 
fossa,  and  is  moved  up  to  the  right  lumbar  region,  when  the 
manipulation  is  continued  as  already  described.  Meanwhile,  the 
pressure  on  the  left  side  of  the  abdomen  is  relieved  in  consequence 
of  the  pronation  of  the  forearm  and  extension  of  the  metacarpo- 
phalangeal joints,  and  the  fingers  are  brought  lightly  back  to  the 
transverse  colon  again. 

During  the  whole  of  this  the  grasp  of  the  middle  part  of  the 
abdomen  must  never  be  lost ;  the  hand  itself  describes  a  small 
circle  and  acts  chiefly  on  the  small  intestines,  while  the  fingers 
and  thumb  describe  a  segment  of  a  large  circle  and  act  chiefly 
along  the  large  intestine.  In  this  way  the  contents  of  the 
abdomen,  especially  the  intestines,  are  kneaded. 

The  other  hand  of  the  assistant  can  be  placed  over  the  thumb 
to  help  it  in  its  onward  course. 

The  above  division  of  the  manipulation  into  separate  parts  is 
merely  for  the  sake  of  description ;  in  reality  the  various  parts 
should  merge  into  one  another  evenly  and  without  a  break. 

Physiological  effect  of  stomach  exercise. — The  various  resulting 
physiological  phenomena  are  so  intimately  bound  up  together 
that  it  is  impossible  either  to  distinguish  them  separately  or  to 
state  definitely  how  far  primary  are  modified  by  secondary  effects. 


GYMNASTIC   MOVEMENTS  229 

Also  they  vary  according  to  the  force  and  duration  of  the 
manipulation.  The  following  are  the  effects  of  stomach  exercise 
as  ordinarily  given  in  order  to  act  beneficially  on  the  digestive 
apparatus : — 

(1)  From  the  alternate  application  and  removal  of  pressure, 
and  alternate  lengthening  and  shortening  of  the  vessels,  the 
venous  return  is  hastened  in  both  the  portal  vein  and  the 
inferior  vena  cava.  Unless  the  exercise  be  carried  out  very 
energetically  so  as  to  cause  vaso-constriction,  there  is  vaso- 
dilatation of  the  arteries  of  the  splanchnic  area.  As  regards  the 
further  effect  on  the  latter,  it  is  difficult  to  generalise,  for  different 
cases  yield  different  results.  Perhaps  this  is  due  to  varying 
degrees  of  excitability  of  the  vagus  and  abdominal  sympathetic. 
Vaso-dilatation  of  the  splanchnic  arteries  is  accompanied  by 
a  fall  in  the  general  blood  pressure  ;  with  vaso-constriction  the 
opposite  is  the  case. 

(2)  There  is  reflex  slowing  of  the  heart ;  this  arises  from 
almost  any  form  of  stimulation  of  the  abdominal  viscera  (the  so- 
called  Goltz^  phenomenon).  It  is  probably  a  reflex  through  the 
vagus  (Goltz) .  If  executed  very  energetically,  however,  stomach 
exercise  may  cause  cardio-acceleration.  It  is  a  point  of  interest 
that  observers  are  frequently  at  variance  regarding  the  effect  of 
"abdominal  massage"  on  the  heart;  this  is  no  doubt  due  to 
differences  in  the  method,  strength,  and  time  of  the  manipulation. 

(3)  The  mechanical  application  and  removal  of  pressure, 
together  with  the  improved  circulation,  stimulates  the  abdominal 
viscera,  i.e.,  increased  peristalsis  results,  with  consequent 
increased  growth  in  the  muscle  of  the  intestine-  and  stomach 
proper.  This  reacts  on  the  venous  return.  "Peristalsis  of  the 
intestine  greatly  promotes  the  portal  venous  flow."  (Hill.^) 

(4)  There  is  an  increased  churning  up  of  the  contents  of  the 
intestine  and  stomach  proper,  brought  about  partly  by  increased 
vital  activity  in  these  parts,  and  partly  from  the  mechanical 
alternate   application    and   removal   of   pressure.     The   contents 

'Sec  "Vagus  u.  Herz "  in  Virchow's  Archiv,  1863,  vol.  xxvi.,  pp.  1-33;  and 
"  tjber  den  Einfluss  des  Centralnervensystems  auf  die  Blutbeweguug.,"  in  ibid, 
1863,  vol.  xxviii.,  pp.  428-432. 

-Hj.  Ling  considered  that  this  was  partly  brought  about  by  reflex  action  through 
stimulation  o£  the  abdominal  parietes.  Cf.  "  De  Fiirsta  Begreppen  a£  Rorelselaran," 
1866,  pp.  62,  &c. ;  "Forkortad  Ofversigt  af  AUman  Rorelseliira,"  1880,  pp.  18,  &c.  ; 
preface  to  Branting's  "  Efterlemnade  Skrifter,"  1882,  pp.  xxxi. ,  &c. 

"In  Schiifer's  "  Textbook  of  Physiology,"  vol.  ii.,  1900,  p.  121. 


230  ELEMENTS   OF   KELLGREN'S  MANUAL    TREATMENT 

of  both  stomach  and  intestine  will  pass  on  quickei' ;  this  will  in 
itself  stimulate  the  intestine  to  increased  contraction. 

(5)  Improvement  takes  place  in  the  secretion  of  gastric  and 
intestinal  juice. 

(6)  Increased  absorption  by  the  lacteals  results. 

(7)  The  kidneys  are  stimulated. 

(8)  The  liver  is  stimulated.  This  is  partly  due  to  reflex 
irritation  from  the  intestine,  and  partly  to  promotion  of  the 
portal  flow,  and  partly  for  the  reason  given  in   (3). 

(9)  Probably  the  pancreas  is  affected,  the  secretion  of  its  juice 
being  improved.     (See  p.  153.) 

(10)  The  abdominal  parieties  are  stimulated,  but  only  to  a 
slight  extent,  as  they  move  together  with  the  assistant's  hand. 
Reflex  contraction  of  these  muscles,  as  in  phthisis  pulmonum, 
cardiac  conditions  and  intestinal  disorders,  can,  however,  be  over- 
come by  properly  applied  stomach  exercise  at  first  given  gently. 

(11)  Sometimes  there  is  an  effect  on  the  cerebro-spinal  system. 
This  effect  has  as  yet  hardly  received  any  attention,  but  in  some 
cases  it  is  quite  undoubted.  In  one  case  of  paralysis  agitans  I 
observed  that  the  tremors  were  entirely  suspended  during  the 
stomach  exercise,  to  return  again  at  its  close.  Frictions  and 
vibrations  on  the  abdominal  intercostal  nerves  and  abdominal 
sympathetic  produced  no  such  effect. 

If  the  stomach  exercise  be  given  very  gently,  as  in  cases  of 
acute  peritonitis,  acute  enteritis,  &c.,  which  are  on  the  way  to 
recovery,  the  effects  are  chiefly  as  follows  : — 

(1)  The  venous  return  is  promoted  without  a  vaso-dilatation 
ensuing. 

(2)  Excess  of  peristaltic  action  is  removed. 

(3)  Pathological  increase  in  the  secretions  is  diminished. 

(4)  Pain  is  removed. 

(5)  Adhesions  are  broken  down  so  gently  that  no  irritation 
results. 

(6)  Reflex  contraction  of  the  abdominal  muscles  is  removed. 

Comparison     between     Kellgren's     Stomach     Exercise     and    the 
"Abdominal  Massage"  of  other   Schools. 

(1)  "  Abdominal  massage  "  is  frequently  administered  on  the 
bare  skin.     This  method  carries  with  it  the  drawbacks  of  pre- 


GYMNASTIC   MOVEMENTS  j  ■     [^231 

venting  perspiration  and  probably  giving  rise  to  massage  eruptions, 
as  in  the  case  of  massage  of  muscles  (pp.  211,  212),  and  also 
comes  into  conflict  with  the  objection  which  exists  to  uncovering 
the  abdomen  in  female  patients. 

(2)  "  Abdominal  massage  "  is  usually  executed  with  a  great 
deal  more  force,  the  gymnast's  forearm  being  at  right  angles  to 
the  patient's  abdomen,  his  wrist  dorsiflexed  as  far  as  possible  and 
his  hand  dug  deep  into  the  abdomen.  This  is  the  cause  of  the 
frequently  mentioned  fact  that  "  the  first  few  massage  seances  are 
spent  in  overcoming  the  reflex  contraction  and  irritation  of  the 
abdominal  muscles."  I  myself  have  hardly  ever  seen  this  reflex 
contraction  of  muscles  excepting  in  the  case  of  patients  especially 
sensitive  to  tickling,  or,  of  course,  in  acute  inflammatory  con- 
ditions of  the  abdomen. 

(3)  When  performing  "  abdominal  massage,"  the  gymnast  is 
nearly  always  placed  so  as  to  look  transversely  across  the  patient's 
abdomen.'  Not  merely  is  this  position  more  awkward  than  the 
one  adopted  for  carrying  out  Kellgren's  stomach  exercise,  but 
the  mianipulation  itself  becomes  more  clumsy  and  the  proper 
direction  of  the  movement  less  easy  to  maintain  ;  it  also  becomes 
more  difficult  to  watch  the  expression  of  the  patient's  face,  which 
is  one  of  the  best  indicators  of  a  tender  area  being  handled. 

Lists  of  the  literature  on  the  physiological  effects  of  "  abdom- 
inal massage  "  can  be  found  in  the  books  quoted  on  p.  212. 

For  Various  Organa  of  the  Abdomen. 
(Exclusive  of  the  genital  organs.) 

(1)  Stomach  proper. — Shaking  or  vibration  may  be  performed 
with  tbe  fingers  gently  pressed  in  fairly  deeply  at  the  left  costal 
margin  anteriorly  at  about  the  eighth  to  ninth  ribs ;  the  direc- 
tion of  the  manipulation  should  be  downwards  and  somewhat 
inwards.  Frictions  on  the  sixth  to  eighth  left  dorsal  nerves  near 
the  spine  (see  p.  164)  can  be  executed  simultaneously. 

(2)  Liver  and  gall-bladder. — These  organs  may  be  stimulated 

'  C/.  Wide,  "Handbok  i  Mediciusk  Gymnastik,"  1825,  p.  50;  "Handbook  of 
Medical  Gymnastics,"  1899,  p.  49;  "Handbok  i  Medicinsk  och  Ortopedisk  Gym- 
nastik," 1902,  p.  47;  "Handbook  of  Medical  and  Orthopfedic  Gymnastics,"  190.3, 
p.  07. 


232  ELEMENTS  OF   KELLGREN'S   MANUAL   TREATMENT 

by  means  of  running  vil)rations  or  frictions  along  the  lower  costal 
margin  of  the  right  side  ;  or  the  gall-bladder  and  sixth  and  seventh 
right  dorsal  nerves  may  be  worked  simultaneously.  One  hand 
attends  to  the  latter,  as  directed  on  p.  164,  while  the  terminal 
phalanges  of  the  third  and  fourth  fingers  of  the  other  hand 
execute  frictions  downwards  and  inwards  (in  the  direction  of  the 
ducts)  at  the  inner  end  of  the  ninth  and  tenth  costal  cartilages. 

Shaking  or  vibration  of  the  liver  may  be  performed  with  the 
finger  tips  placed  under  the  right  costal  margin  anteriorly ;  the 
manipulation  is  applied  in  an  upward  and  outwai'd  direction. 

(3)  Spleen. — The  fingers  are  placed  under  the  left  costal 
margin  and  the  frictions  are  executed  directly  inwards  at  the  level 
of  the  tenth  rib.  The  ninth  and  tenth  dorsal  nerves  of  the  left 
side  (see  p.  165)  can  at  the  same  time  be  conveniently  stimulated. 

Vibrations  over  the  spleen  can  also  be  executed  with  the 
fingers  placed  over  the  ninth  to  eleventh  ribs  in  about  the  mid- 
axillary  line. 

(4)  Individual  parts  of  the  small  or  large  intestine.— Frictions, 
shakings,  or  vibrations  can  be  executed  over  any  part  that  is  the 
seat  of  local  pain,  distension,  &c.  The  direction  of  the  manipula- 
tion depends  on  the  site  affected ;  as  a  general  rule  it  is  in  the 
direction  of  the  progress  of  the  intestinal  contents.  In  some  cases 
of  intestinal  obstruction,  however,  it  is  carried  out  in  the  opposite 
direction,  so  as  to  diminish  the  tension  and  thereby  aid  in 
removing  the  obstruction. 

Vibrations  may  be  executed  over  any  part  that  is  acutely 
inflamed,  either  locally  or  generally.  A  good  example  of  the 
former  is  appendix  vibration  (see  appendicitis). 

(5)  Pancreas. — The  fingers  of  each  hand  are  placed  about  mid- 
way between  the  umbilicus  and  the  xiphisternum,  about  an  inch 
from  the  middle  line,  and  the  frictions  administered  inwards  and 
upwards;  clinical  experience  teaches  that  this  is  the  best  method, 
although  the  precise  reason  has  not  yet  been  ascertained. 

(6)  Kidneys. — Frictions  or  vibrations  may  be  executed  trans- 
versely across  these  glands  just  below  the  twelfth  rib  at  the 
outer  edge  of  the  erector  spinse.  The  method  of  reaching  the 
kidneys  from  the  front  has  been  described  on  p.  167.  If  one 
kidney  be  treated  at  a  time,  one  hand  manipulates  from  the  front, 
and  the  other  treats  the  tenth,  eleventh  and  twelfth  dorsal  nerves, 
as  described  on  p.  165. 


GYMNASTIC   MOVEMENTS  za 

(7)  Bladder. — Suprapubic  vibration  and  shaking  has  been  fully 
entered  into  already  (pp.  168,  169). 

(8)  Anus. — Frictions  may  be  made  use  of  in  cases  of  an  incom- 
petent sphincter.  It  is  often  useful  in  these  cases  to  make  the 
patient  do  rectum  lifting,  PA,  while  the  frictions  are  being 
administered,  as  follows :  the  patient  must  try  and  draw  up  his 
rectum  and  close  the  sphincter,  thus  exercising  the  muscles  that 
retain  control  over  the  fasces.  Vibrations  of  the  anus  given  with 
the  last  phalanx  of  one  or  two  fingers  are  useful  for  irritative  or 
inflamed  conditions,  and  for  hfemorrhoids. 

(9)  Of  the  anal  canal. — The  forefinger  is  passed  in  as  in 
the  ordinary  way  for  making  a  rectal  examination,  and  then 
vibrations  are  set  up.  If  spasm  of  the  sphincter  be  present,  the 
finger  should  vibrate  from  the  beginning  of  the  attempt  to  obtain 
its  passage  ;  this  will  generally  succeed  in  overcoming  the  spasm 
with  the  minimum  amount  of  pain. 


(8)  Genital  Organs. 
(A)  Male. 

(a)  Prostate  gland. — The  patient  assumes  crook  half  lying  or 
half  lying  position,  with  the  knees  somewhat  separated.  The 
assistant  places  the  terminal  phalanx  of  his  forefinger  about  an 
inch  behind  the  symphysis  pubis  and  executes  vibrations, 
shakings,  or  frictions,  as  the  case  demands,  from  behind  for- 
wards. That  the  sympathetic  nerves  are  stimulated  is  shown 
by  the  fact  that  in  some  patients  a  rush  of  blood  to  the  head 
takes  place,  just  as  in  consequence  of  shaking  over  the  bladder. 

{b)  Testicle,  dc. — The  assistant  very  gently  grasps  the  testicle 
from  above  with  the  fingers  and  thumb  of  one  hand,  while  his 
other  hand  grasps  it  from  below.  Or  he  may  employ  only  one 
hand,  and  very  gently  grasp  the  testicle  between  the  fingers  and 
thumb  respectively.  He  then  administers  the  vibrations.  The 
epididymis,  after  being  very  gently  grasped  between  the  fingers 
and  thumb,  may  also  be  vibrated. 

(c)  Sperviatic  cord. — Vibrations  and  frictions  at  right  angles 
to  its  course  may  be  executed  over  this  structure  as  it  lies  in  the 
inguinal  canal. 


234  ELEMENTS    OF    KELLGREN'S    MANUAL  TREATMENT 

(B)  Female. 

Disorders  of  menstruation  were  treated  by  P.  H.  Ling,  and 
a  few  cases  of  female  pelvic  disease  were  from  time  to  time 
treated  by  Branting/  Neumann,^  Melicher,'  &c.  To  Thure 
Brandt/  however,  belongs  the  credit  of  having  devised  a  sys- 
tematic gymnastic  method  for  treating  uterine  and  ovarian 
disease. 

The  following  are  among  the  movements  most  commonly 
employed  by  Henrik  Kellgren  : — 

I. — Non-Pregnant. 

(1)   Uterus. 

Heave  Grasp  Standing  Suprapubic  Kneading,  PP. 

The  patient  assumes  heave  grasp  standing  position.  The 
operator,  sitting  on  a  low  stool  in  front  of  her  and  rather  to  her 
right  side,  places  the  left  hand  over  the  sacrum  to  steady  the" 
patient,  and  the  right  hand  over  the  lower  part  of  the  abdomen, 
so  that  the  proximal  part  of  that  palm  rests  above  the  pubis  and 
the  rest  of  the  hand  over  the  hypogastric  region,  with  the  fingers 
pointing  directly  upwards.  The  fingers  and  thumb  are  then 
somewhat  flexed,  and  the  thumb  and  little  finger  somewhat 
opposed-  Thus  the  lower  part  of  the  abdomen,  and  with  it, 
of  course,  the  uterus,  is  grasped  in  the  hand.  Then,  continually 
applying  a  certain  amount  of  pressure  upwards,  so  as  to  lift 
this  part,  a  series  of  circular  movements  is  made  in  a  negative 
direction  as  seen  from  the  front,  \vith  alternating  application 
and  removal  of  lateral  pressure  from  the  thenar  and  hypothenar 
eminences. 

This  exercise  promotes  the  circulation  in  the  uterus  and 
pelvic  organs  as  a  whole.  It  also  tends  to  correct  pendulous 
abdomen.  The  bladder  is  sometimes  stimulated  to  contraction, 
resulting  in  a  desire  for  micturition. 

'  See  gymnastic  prescriptions  in  "  Efterlemnade  Skrifter,"  1882. 

-  "Therapie  der  chroulschen  Krankheiten,"  1857,  p.  213. 

■'  "  Erster  Bericht,"  &c.,  1853,  pp.  4,  5  ;  "  Jahresbericht  fur  1853,"  1854,  pp.  35, 
&c.  ;  "Jahresbericht  fiir  1854,"  1855,  pp.  20,  &c. ;  "Jahresbericht  fur  1855,"  1856, 
p.  30;  "Jahresbericht  fur  1856  und  1857,"  1858,  pp.  36,  &c. 

'  Tlie  following  are  the  chief  works  of  Thure  Brandt : — "  Om  Behandliug  af  Uter- 
inlidanden  och  Prolapser  med  Medikal  Gj'mnastik,"  1864 ;  "  Nouvelle  niethode 
gymnastique  et  magnetique  pour  le  traitement  de  maladies  des  organes  du  bassin  et 
principalement  les  affections  uterines,"  1868  ;  "Massage  bei  Fraucnleiden  (Behaud- 
lung  weiblicher  Geschlechtskrankheiten),"  1890,  1893,  1897. 


GYMNASTIC   MOVEMENTS  235 

For  all  the  following  movements  the  patient  is  to  be  placed  in 
half  lying  or  crook  half  lying  position. 

(a)  External  Treatment. 

Sitprapuhic  uterine  frictions. — In  some  cases  the  uterus  can 
be  stimulated  to  contraction  by  executing  frictions  at  the  side  of 
the  symphysis  pubis  about  two  inches  from  the  middle  line. 

Uterine  vibrations  through  the  ahdotninal  tvall. — The  tips  of 
the  fingers  and  thumb  are  placed  over  the  uterus,  grasping  it  if 
convenient,  and  then  vibrations  are  set  up. 

Uterine  frictions  through  the  abdominal  tvall. — May  be 
executed  with  the  fingers  in  the  hypogastric  region  over  the 
uterus  in  a  direction  from  above  downwards. 

Bimanual  uterine  liftinrj  through  the  abdominal  wall. — The 
operator  stands  at  the  patient's  head  and  looks  towards  her  feet. 
The  hands  are  then  gently  pressed  in  on  either  side  in  the  iliac 
fossEe  low  down,  in  an  inward  and  downward  direction,  until  the 
fingers  close  on  the  lower  part  of  the  uterus.  They  then  lift  that 
organ  in  an  upward  and  forward  direction.  This  lifting  may  be 
carried  out  with  simultaneous  vibration. 

(b)  Internal  Treatment. 

It  isi  mperative  that  all  cases  of  internal  treatment  be 
handled  only  by  a  very  skilled  operator  and  in  such  a  way  as 
to  cause  absolutely  no  sexual  excitement. 

Uterine  vibration  (internal). — The  forefinger  is  passed  in  the 
usual  way  into  the  vagina  until  it  touches  the  cervix  and  is  then 
set  into  vibration. 

Uterine  frictions  (external)  with  uterine  vibration  (internal). — 
In  cases  of  obstinate  chronic  inflammatory  conditions  of  the 
uterus  or  leucorrhoea  from  that  organ,  these  two  manipulations 
can  be  combined. 

Uterine  lifting  (internal). — The  forefinger  of  one  hand  is 
passed  in  in  the  usual  way,  and  when  it  has  reached  the  cervix  is 
gently  pushed  up,  vibrating  all  the  time,  so  that  the  cervix  (and 
rvith  it,  of  course,  the  uterus)  is  lifted  upwards.  The  other  hand 
may  be  used  if  necessary  through  the  anterior  abdominal  wall  to 
guide  the  uterus  in  its  course  and  prevent  displacement. 


236  ELEMENTS  OF  KELLGREN'S    MANUAL    TREATMENT 

In  cases  of  bad  prolapse  with  or  without  inversion,  the  proce- 
dure is  practically  the  same,  i.e.,  gently  lifting  up  the  protruding 
parts  with  simultaneous  vibration.  This  should  be  supplemented 
by  strong  frictions  on  the  posterior  sacral  nerves  and  on  the  sub- 
trapezial  plexus. 

Bepositions  of  malplacements  of  the  uterus. — No  special  direc- 
tions can  be  given,  as  each  case  must  be  treated  according  to  its 
nature.  Simultaneous  vibration  of  the  manipulating  hands  often 
facilitates  the  replacement  of  this  organ. 


(2)    Ovaries. 

Frictions '  on  the  ovaries. — The  patient  assumes  the  half  lying 
position.  The  palmar  surfaces  of  the  distal  parts  of  the  fingers 
of  both  hands  are  placed  respectively  one  on  each  side  of  the 
abdomen  about  two  inches  internal  to  and  two  inches  below 
the  anterior  superior  spine.  Then,  generating  the  movement 
almost  exclusively  from  the  metacarpo-phalangeal  joints,  and 
keeping  the  joints  of  the  fingers  extended,  the  frictions  are  gently 
executed  in  a  direction  downwards  and  inwards. 

Vibrations  on  the  ovaries  can  be  executed  with  the  fingers 
placed  over  on  the  same  spot  as  for  executing  frictions. 

There  is  no  reason  why  the  treatment  should  be  discontinued 
during  the  menstrual  period  ;  on  the  contrary,  in  most  cases  it  is 
better  to  continue  with  it  during  that  time.  Exercises  of  an 
exerting  nature  or  that  draw  blood  from  the  pelvis  (excepting  in 
cases  of  menorrhagia  or  metrorrhagia)  can  be  omitted  ;  but  the 
rest  of  the  daily  treatment  should  be  carried  out  as  usual.  It  is 
noteworthy  that  female  patients,  when  under  the  manual  treat- 
ment, often  show  greater  improvement  just  after  menstruation 
than  during  the  rest  of  the  previous  month.  I  have  personally 
verified  this  even  in  cases  of  such  diseases  as  chronic  adhesive 
pleurisy  and  facial  paralysis,  which  it  might  be  imagined  would 
be  unaffected  by  menstruation.  This  tends  to  show  that  the 
flow  can  act  as  a  general  eliminator  in  conditions  apart  from 
pelvic  disorders. 

'  "  Frictions"  is  not  really  a  good  term,  as  the  movement  is  in  most  cases  a  very 
gentle  one,  but  there  is  no  better  word  to  replace  it.  In  atrophic  conditions  of  the 
glands,  however,  as  in  premature  menopause,  the  manipulation  is  executed  more 
energetically  and  in  reality  becomes  "  frictions." 


GYMNASTIC   MOVEMENTS  237 

II. — Pregnant. 

Respiratory  exercises  aud  trunk  movements  carried  out  during 
pregnancy  in  order  to  promote  the  abdominal  circulation  and 
strengthen  the  muscular  walls  of  the  abdomen'  will  often  have 
a  very  beneficial  effect  on  the  patient.  Such  exercises  as  loin 
lean  stride  standing  alternate  rotation,  AR,  ringing,  PP ;  sit 
lying  back  raising,  PA,  &c.,  are  very  suitable,  and  I  have  never 
known  them  to  cause  the  slightest  symptom  of  threatening  abor- 
tion— on  the  contrary,  in  conjunction  with  other  manipulations, 
they  can  sometimes  counteract  the  abortive  habitus.  In  such 
cases  the  amount  of  resistance  or  force  applied  should,  of  course, 
be  moderated  somewhat,  and  during  the  course  of  all  the  above 
exercises  the  patient  must  draw  her  abdomen  upwards  and 
inwards  as  much  as  possible. 

Stomach  exercise,  given  with  a  moderate  amount  of  energy, 
may  be  administered  to  all  pregnant  patients  without  danger  of 
abortion.  It  should,  however,  in  cases  of  abortive  habitus  or  where 
symptoms  of  pelvic  pressure  are  manifested,  be  supplemented  by 
the  so-called  "  uterine  lift-vibration  "  (see  p.  139)  as  follows  :  The 
patient  assumes  the  half  lying  position  ;  the  operator  places  his 
hand  very  much  as  for  suprapubic  kneading  (see  p.  234),  so  that 
his  thumb  and  fingers  gently  close  on  the  lower  part  of  the  uterus. 
Pressing  gently  upwards  with  the  proximal  part  of  his  palm,  the 
fingers  are  slightly  approximated,  and  then  lift  the  whole  uterus 
upwards  ;  they  then  vibrate  that  organ  for  one  to  five  minutes. 
In  one  case  of  threatening  abortion  at  the  sixth  month,  with 
uterine  "  pains,"  in  a  patient  who  had  continually  been  having 
miscarriages  ever  since  her  first  confinement  twenty  years 
previously,  this  uterine  lift-vibration  given  at  intervals  for  about 
an  hour,  stopped  the  uterine  pains  and  prevented  abortion.  This 
movement,  together  with  other  trunk  and  leg  exercises,  was 
performed  daily,  and  at  the  ninth  month  a  normal  confinement 
took  place  with  satisfactory  issue. 

III. — During  Labour. 

Frictions  on  the  posterior  sacral  nerves  (especially  the  third 
and   fourth)    and  on  the  lumbar   nerves,   executed  during  each 

'  Cf.  Georgii,  "  Kinetic  Jottiugs,"  1880,  p.  87. 


238    ELEMENTS    OF   KELLGREN'S   MANUAL    TREATMENT 

uterine  pain,  seem  to  aid  materially  in  the  expulsion  of  the  foetus 
and  afterwards  of  the  placenta ;  they  certainly  diminish  the  pain 
in  the  back  that  is  so  often  present,  and  make  the  patient  feel 
more  comfortable.  Strong  vibration  on  the  coronal  suture  during 
the  pains  has  in  many  cases  a  stimulatory  effect. 

IV. — POST-PARTUM     AND     PUERPERIDM. 

As  soon  as  possible  after  the  expulsion  of  the  foetus  stomach 
exercise  should  be  given,  alternating  with  uterine  suction  vibra- 
tions or  friction  vibrations  with  suction,  given  with  the  hand 
placed  over  the  fundus.  In  cases  of  inertia  uteri  or  post- 
partum hemorrhage,  frictions  on  the  posterior  sacral  nerves 
and  on  the  uterus  itself  can  be  used  simultaneously.  If  these  fail 
to  stop  the  hsemorrhage,  the  latter  can  sometimes  be  arrested  b}' 
passing  the  fingers  of  both  hands  deep  into  the  abdomen  at  the 
side  of  the  uterus  just  above  the  symphysis  pubis  and  setting  up 
very  strong  vibrations  or  shakings. 

For  the  first  week  or  so  after  the  confinement,  stomach 
exercise,  uterine  suction  vibrations  or  frictions  and  spinal  nerve 
frictions  (especially  sacral  and  lumbar)  should  be  administered 
morning  and  evening.  During  the  second  and  third  week  they 
need,  as  a  general  rule,  be  only  administered  once  a  day.  About 
the  fourth  day  after  the  confinement,  i.e.,  when  the  danger  of 
puerperal  fever  is  over,  the  patient,  if  otherwise  strong  and 
healthy,  should  be  encouraged  to  get  up  and  move  about,  and  one 
or  two  mild  trunk  movements  may  be  performed  in  order  to 
exercise  the  anterior  abdominal  muscles  and  to  promote  the 
abdominal  circulation,  e.g.,  sit  lying  back  raising,  PA,  (with 
assistance  if  needed). 

The  recumbent  position  during  the  puerperium  has  always  been 
advocated  by  the  profession  chiefly  for  the  following  reasons  : — 

(1)  To  enable  the  patient  to  regain  strength. 

(2)  To  prevent  prolapse  and  displacements. 

(8)  To  enable  the  abdominal  muscles  to  recover  their  tone. 

(4)  To  enable  the  uterus  to  return  to  its  proper  size. 

(5)  To  prevent  the  entrance  of  septic  matter. 

In  Kellgren's  methods  the  reasons  for  preferring  gymnastic 
exercises  are  as  follows  : — 

(1)  The  patient  is  enabled  to  regain  strength  by  exercising  the 


GYMNASTIC   MOVEMENTS  239 

muscles  of  her  body  as  a  whole.  Voluntary  muscles  do  not  gain 
strength  by  being  kept  in  a  state  of  prolonged  rest  after  the 
effects  of  the  fatigue  of  the  actual  labour  have  passed  away. 

(2)  Prolapse  is  prevented  by  the  strengthening  of  the  pelvic 
and  abdominal  muscles  through  passive  manipulations  such  as 
stomach  exercise  and  uterine  and  sacral  nerve  frictions,  and,  what 
is  far  more  important,  through  active  exercises  in  which  the 
patient  has  to  use  her  own  powers  to  contract  these  muscles  and 
improve  their  tone.  In  cases  where  there  is  a  tendency  to 
backward  displacement,  prolonged  rest  in  bed  wilt,  instead  of 
preventing  such  a  malposition  aid  in  its  establishment,  as  then 
the  force  of  gravity  acts  continually  on  the  uterus,  tending  to 
draw  it  towards  the  sacrum. 

(3)  The  uterus  is  better  enabled  to  perform  involution  to  the 
correct  amount  through  movements  carried  out  to  promote  the 
venous  and  lymphatic  return  (and  thus  getting  rid  of  the  waste 
products)  and  through  stomach  exercise  and  other  manipulations 
carried  out  to  stimulate  it  to  contraction,  than  by  keeping  the 
patient  in  a  position  of  rest  by  means  of  which  a  tendency  to 
venous  and  lymphatic  stasis  and  hypostatic  congestion  is 
produced. 

(4)  The  entrance  of  septic  matter  is  prevented  just  as  easily 
with  the  patient  up  and  walking  about ;  and  the  danger  of  its 
obtaining  a  foothold  in  the  case  of  entrance  into  the  uterus  is 
much  less  when  the  uterus  is  in  a  healthy  active  condition  than 
when  it  is  inactive  through  prolonged  rest. 


An  exercise  often  prescribed  as  a  general  tonic  is  known  as 


Forwards  Lying  Back  Exercise,  PP  (and  PA). 

The    patient    assumes    the    forwards    lying    position.       The 
assistant — 

(1)  Executes  head  to  foot  running  nerve  frictions ; 

(2)  Performs  length  hacking  ; 

(3)  Administers  a  rapid  stroking,  only  once,  on  the  posterior 
aspect  of  the  body  from  shoulder  to  heels. 

The    assistant's    manipulations    being    ended,    the    patient 
performs  back  arching,  breathnig,  PA. 


CHAPTER  VI. 

CONCLUDING   REMARKS  TO   PART   I. 

I  HAVE  now  briefl}-  described  the  more  important  exercises 
and  manipulations  as  practised  by  Henrik  Kellgren.  It  is,  how- 
ever, possible  to  vary  them  infinitely  ;  they  may  be  specially 
modified  and  adapted  to  each  particular  case  in  order  to  produce 
the  maximum  beneficial  effect.  This  has  already  been  specially 
insisted  on  in  more  than  one  instance.  In  some  cases  it  may 
become  necessary  to  alter  exercises  so  much  that  the  process 
practically  amounts  to  inventing  new  ones.  As  a  general  rule, 
passive  movements  lend  themselves  far  more  convenientlj'  to 
modification  than  duplicate  ones,  especially  such  complex  forms 
as  head  exercise,  stomach  exercise,  &c.  Experience  alone  can 
enable  the  assistant  to  suit  these  movements  to  each  patient,  and 
to  adapt  them  day  by  daj'  to  his  progress. 

Modifications  may  be  made  as  regards : — 

(1)  The  initial  position.  The  greater  the  difficulty  of  assuming 
the  initial  position,  the  less  can  the  patient  concentrate  his  energj' 
on  the  actual  movement  performed  from  it.  This  may  or  may 
not  be  of  advantage.  When  patients  are  confined  to  their  beds 
all  movements  are,  of  course,  given  to  them  while  they  are  in 
lying,  half  lying,  side  lying,  or  sitting  positions;  in  acute  cases 
the  patient  may  be  allowed  to  occupy  whatever  posture  is  most 
comfortable,  provided  it  neither  impedes  the  administration  of  the 
actual  manipulation  nor  impairs  its  beneficial  effect.  The  rule 
that  all  initial  positions  must  be  carefully  and  correctly  assumed 
and  maintained  during  the  whole  performance  of  a  movement 
from  beginning  to  end  may  in  such  cases  be  suspended.  Devia- 
tions from  the  same  rule  are  also  permitted  when  certain  passive 
movements  are  administered  to  a  patient  occupying  lying  or 
sitting  positions,  e.g.,  there  can  be  no  objection  to  letting  a  patient 
change  the  position  of  a  foot  for  comfort's  sake  during  the  time 
that  he  is  undergoing  a  length}-  head  exercise. 


CONCLUDING    REMARKS    TO    PART    I. 


241 


(2)  The  energy  with  which  passive  movements  are  given,  or 
with  which  the  opposing  force  is  offered  in  duplicate  movements. 

(3)  The  rapidity  with  which  a  movement  is  performed. 

(4)  The  frequency  of  repetition,  or  period  of  application  (in 
active  and  passive  movements  respectively). 

(5)  The  length  of  the  pause  between  the  repetitions. 

(6)  The  order  of  arrangement  of  the  exercises  in  the  daily 
programme.  For  example,  two  consecutive  exercises  which  call 
the  same  muscles  into  action  will  be  more  tiring  than  if  separated 
by  movements  involving  other  muscles. 

(7)  The  administration  of  two  or  more  passive  manipulations 
simultaneously. 

(8)  The  withdrawal  or  reversal  of  direction  of  the  whole  or 
part  of  the  resistance  ;  e.g.,  ride  sitting  arm  abduction  AE,  adduc- 
tion PR,  exercises  the  abductors  ;  but  if  given  as  abduction  PR, 
adduction  AR,  the  antagonists  (adductors)  are  exercised.  As  an 
example  of  possible  variations  I  may  specify  the  following  :  half 
lying  foot  flexion  and  extension  (already  described  on  pp.  69,  70). 


Extension. 

Flexobs. 

EXTENSOBS. 

Flexion. 

s. 

'H-S 

0  i 

3.S 

1 

1^  d 

*  0" 

ll 

PP. 
PP. 
PP. 
PP. 

PA. 
PA. 

PA. 
PA. 

AR. 
AR. 
AR. 
AR. 
PR. 
PR. 
PR. 
PR. 

PP. 

PA. 
AR. 
PR. 
PP. 
PA. 
AR. 
PR. 
PP. 
PA. 
AR. 
PR. 
PP. 
PA. 
AR. 
PR. 

X 
X 
X 
X 

X 
X 
X 
X 

X 
X 
X 
X 

X 
X 
X 
X 

X 
X 
X 
X 

X 
X 

X 
X 

X 
X 
X 

X 

X 
X 

From  the  very  nature  of  Swedish  medical  gymnastics  various 
persons  have  argued  that  it  would  be  possible  to  devise  mechanical 
16 


242    ELEMENTS  OF  KELLGREN'S  MANUAL  TREATMENT 

appliances,'  wbich,  if  constructed  with  weights  and  levers  for  the 
active  movements,  and  furnished  with  an  engine  to  supply 
the  motive  power  for  the  passive  ones,  would  advantageously 
replace  the  assistant's  hands  in  administering  the  exercises  ;  and 
during  the  last  fifty  years  such  machines  have  been  invented  and 
constructed.  They  have  gained  great  popularity  amongst  a 
certain  class  of  gymnasts,  chiefly  on  account  of  the  following 
reasons : — 

Firstly,  no  manual  skill  is  required  on  the  part  of  the  gym- 
nast; secondly,  the  gymnast  saves  himself  fatigue  and  expenditure 
of  time ;  and,  thirdly,  he  can  have  many  more  patients  under  his 
care  at  once.  All  these  conditions  are  advantageous  to  the 
manipulator,  but  the  reverse  to  the  patient,  as  the  following 
considerations  will  show  : — 

(1)  Machines  can  only  partially  adapt  themselves  to  differences 
in  the  size,  adiposity,  &c.,  of  different  patients. 

(2)  They  cannot  adapt  themselves  to  the  daily  variation  of  each 
individual  patient. 

(3)  They  cannot  encourage  the  patient  by  admonishing  him  to 
do  his  best. 

(4)  They  cannot  by  themselves  regulate  the  specific  rate  of  the 
movement. 

(6)  They  cannot  prevent  the  patient  from  turning  a  passive 
movement  at  a  joint  into  an  active  one. 

(6)  Only  a  limited  number  of  initial  positions  are  permitted  by 
them,  and  only  a  limited  number  of  movements  can  be  executed 
by  them. 

(7)  They  cannot  administer  an  exercise  that  involves  pain  for 
many  days  running,  as  the  patient  will  (even  insensibly)  adopt 
some  means  of  nullifying  it,  such  as  a  faulty  position,  or  a  wrong 
muscular  action. 

(8)  Some  exercises  can  under  no  circumstances  be  executed  by 
a  machine  ;  the  human  hand,  guided  by  the  human  brain,  is  often 
the  only  possible  agent  of  manipulation.  No  machine  has  yet 
been  constructed  capable  of  correctly  giving  such  complicated  and 
varying  movements  as  stomach  exercise  or  arm  nerve  frictions 
(on  the  deep  lying  trunks) ;  I  think  I  may  add  that  no  such 
machine  will  ever  be  produced. 

'  Under  mechanical  appliances  I  do  iint,  of  course,  include  such  apparatus  as 
couches,  chairs,  horizontal  bar.s,  &c.,  which  are  used  to  enable  the  patient  to  assume 
different  initial  positions,  and  also  for  isolation  or  steadying  purposes. 


CONCLUDING    REMARKS    TO    PART    I.  243 

(9)  They  cannot  observe  in  the  patient  changes  for  the  ivorse, 
or  new  symptoms  pointing  to  complications,  &c.,  and  then  act 
accordingly. 

(10)  They  cannot  apply  traction  and  graduate  it  to  suit  each 
patient. 

(11)  The  question  of  manual  v.  machine  vibrations  has  been 
discussed  on  pp.  182,  183. 

The  G.  C.  I.  never  employs  machines  to  replace  the  manual 
method,  and  Branting,^  Hj.  Ling,^  Georgii,^  Th.  Brandt,"*  and 
Hartelius  ^  always  considered  the  latter  method  the  superior  one. 
An  exception  might  possibly  be  made  in  the  case  of  vibrations 
and  shakings-;  P.  H.  Liug,^  Branting,'  and  Hartelius,*  say  that 
machines  may  be  used  to  administer  these  manipulations  instead 
of  the  hand.  I  cannot  acquiesce  in  the  statement  that  P.  H.  Ling 
on  several  occasions  declared  that  machines  might  be  constructed 
to  perform  certain  active  exercises  hitherto  executed  manually,  as 
is  implied  by  Zander ; '  the  latter,  however,  confesses  that  it 
depends  upon  verbal  evidence  only.  No  machines  of  any  descrip- 
tion were  used  when  I  was  a  student  at  the  G.  C.  I. 

I  need  scarcely  add  that  Kellgren's  treatment  rigidly  excludes 
all  such  mechanical  appliances  ;  it  relies  solely  on  the  skilled 
hand  governed  by  the  intelligent  brain. 

I  wish  to  take  the  opportunity  of  stating  that  it  is  utterly 
impossible  for  anyone  to  learn  this  treatment  by  reading  descrip- 
tions of  the  movements  and  watching  trained  students  execute 
them.  A  tyro  might  as  well  expect  to  become  an  expert  per- 
former on  the  piano  or  violin  by  learning  the  theory  and  watching 
the  performances  of  professionals.  Several  }'ears  are  necessary, 
even  for  those  with  natural  talent,  both  mental  and  manual,  to 
gain  a  thorough  mastery  of  the  technique  of  the  various  move- 

'  Address  to  the  graduates  of  the  G.  C.  I.,  April  1,  1842. 

-"Porkortad  Ofversigt  af  Allmiin  Rurelseliira,"  1880,  p.  97. 

'"Kinetic  Jottings,"  1830,  pp.  102,  103,  131-1.37. 

'  "  Massage  bei  Fraueuleiden,"  1897,  pp.  19,  20. 

'  "  Gymnastiska  lakttagelser,"  1863,  pp.  50,  &c.  ;  "DenManuella  Metoden  och 
Maskinmetoden  inom  Sjukgymnastiken,"  in  Hygeia,  June,  1873. 

° "  Gymnastikens  Allmiinna  Grander,"  1SG6,  pp.  5S1,  585. 

'  "  Efterlemnade  Skrifter,"  1832,  pp.  167,  168. 

"'Larobok  i  Sjukgymuastik,"  1883,  p.  103;  1892,  p.  101.  See.  also  Murrav, 
Levin,  Thure  Brandt,  &c.,  in  Liedbeck,  "  Vibratorn,  dess  Andamal,  Beskrifning  och 
Anvandning,"  1891,  p.  vi.;  English  translation,  1891,  p.  vi. 

'"  Svar  pa  '  Nagra  ord  till  belysning  af  fragau  om  de  tvenne  olika  gymnastikme- 
toderna,  den  manuella  oeh  den  mekaniska,' "  1872,  p.  5. 


244       ELEMENTS   OF   KELLGREN'S    MANUAL    TREATMENT 

nients."  But  there  is  also  a  great  deal  to  learn  over  and  above  the 
actual  technique.  Capability  of  judging  the  proper  duration  of 
an  exercise  and  of  knowing  what  movements  are  best  suited  to 
the  particular  case  is  essential,  as  is  also  practical  experience  in 
knowing  what  effects  can  or  cannot  be  obtained.  In  serious  cases 
insufficient  knowledge  and  judgment  may  prove  as  dangerous  as 
in  any  other  branch  of  medical  practice. 

No  amount  of  viere  theory  can  ever  teach  one  the  practical  part ; 
to  achieve  the  proper  standard  of  executive  capacity  requires  long 
and  patient  experience.  He  who  shirks  the  latter  will  merely 
become  a  gymnastic  machme  that  will  never  attain  the  requisite 
skill.  In  addition,  after  having  reached  a  certain  level,  he  will 
in  all  probability  fail  to  maintain  it,  and  his  treatment  will 
degenerate  accordingly. 

It  has  lately  become  fashionable  amongst  some  medical  men, 
who  consider  that  the  actual  practice  of  gymnastics  is  quite  beneath 
their  dignity,  to  confine  their  attention  to  making  out  the  diagnosis 
of  their  cases  and  writing  the  gymnastic  prescription,  leaving  the  ad- 
ministration of  the  movements  to  others.  This  can  only  have  one 
result,  namely,  that  any  skill  they  may  have  attained  to  degen- 
erates, and  that  they  lose  their  sensibility  of  touch  and  the  power 
of  estimating  by  feeling  the  condition  of  the  patient.  This 
tendency  of  the  present  day  may  to  some  extent  account  for  the 
variety  of  misinformation  and  number  of  errors  which  abound 
in  books  on  massage  and  gymnastics. 


PART  II. 

PRACTICAL    APPLICATION    OF   THE   TREATMENT, 
ILLUSTRATED   BY   CASES. 


PREFACE. 

I  shall  now  proceed  to  consider  the  practical  application  of 
Kellgren's  manual  treatment,  illustrating  my  remarks  from 
clinical  experience.  In  each  of  the  cases  quoted  (unless  specially 
mentioned)  Kellgren's  treatment  was  the  only  therapeutic  agent 
employed,  and  in  consequence  the  specified  beneficial  results 
were  due  "entirely  to  the  merits  of  that  method  as  opposed  to 
any  other. 

I  have  definite  reasons  for  describing  so  many  cases  in  great 
detail.  Frequent  and  recurring  enquiries  are  made  by  medical 
men  who  have  interested  themselves  in  Kellgren's  treatment  as 
to  the  disappearance  of  or  change  in  one  particular  symptom 
of  a  disease  under  cure.  Further,  the  rapid  course  that  acute 
ailments  take  under  Kellgren's  treatment  is  of  extraordinary 
interest,  and  calls  for  detailed  account ;  it  is,  indeed,  not  too  much 
to  say  that  some  of  the  results  to  be  obtained  will  cause  a 
revolution  in  the  hitherto  ordinarily  accepted  ideas  concerning 
symptoms,  duration,  prognosis,  sequelae,  and  mortality. 

With  regard  to  some  cases,  the  principles  on  which  the 
gymnastic  prescription  depends  is  explained  at  length  ;  with 
regard  to  others,  however,  the  gymnastic  prescription  is  left 
to  explain  itself  in  the  light  of  what  has  already  been  said. 

The  cases  themselves  are  nearly  all  from  my  own  private 
practice,  and  they  date  from  July,  1898,  to  December,  1902. 
Most  of  them  occurred  while  I  was  in  practice  at  Sanna,  which 
is  situated  about  two-thirds  of  a  mile  from  the  town  of  Hus- 
kvarna,  and  about  three  miles  from  the  town  of  Jonkoping,  in 
the  province  of  Smaland,  in   Sweden. 


CHAPTl-ll  I. 

DIAGNOSTIC    EXERCISES. 

Diagnostic;  exercises  are  mentioned  in  the  writings  of  P.  H. 
Ling,'  Neumann,^  liicbter,^  Hj.  Ling,'  and  others. 
Active  exercises  may  be  used  : — 
(i)  To  diagnose  stiffness  or  adhesions  ; 

(2)  To  determine  the  cause  of  pain,  whetlier  local  or  reflex  ; 

(3)  To  diagnose  paresis  or  paralysis  of  groups  of  muscles  or 
individual  muscles  ; 

(4)  To  determine  coordinating  or  inhibiting  power ; 

(.5)  To  diagnose  spastic  conditions,  and  determine  the  presence 
or  absence  of  tremor  ; 

(6)  To  settle  various  points  in  connection  with  irritability  of 
the  heart,  power  to  control  prolapsus  uteri,  herniae,  the  efficiency 
of  the  respiratory  function,  &c.  ; 

(7)  To  determine  the  state  of  voluntary  muscle  action  as 
controlled  by  the  intelligence  in  persons  who  are  imbecile  or 
mentally  deficient ; 

(8)  To  determine  the  causes  that  have  brought  about  de- 
formity, such  as  malposition,  occupation,  &c. 

Passive  movements  at  joints  may  be  used  to  determine  : — 

(1)  The  degree  of  mobility  at  a  joint ; 

(2)  The  looseness  or  weakness  of  a  joint ; 

(3)  Whether  pain  is  local  or  reflex ; 

(4)  The  presence  of  spastic  conditions  ; 

(5)  The  degree  of  extensibility  of  various  muscles  ; 

(6)  The  presence  of  adhesions,  stiffness,  crepitus,  &c. 

'"  Gymnastikens  Allmaana  Grunder,"  1834,  1840,  pp.  O'J,  154,  171,  172;  ibUL, 
1866,  p.  536. 

^  "  Therapie  der  chronischen  Krankheiteu,"  1887,  pp.  32,  &c. 

■' "  Bericht  iiber  neuere  Heilgymnastik,"  in  Schmidt's  Jahrbiicher,  1854,  vol. 
Ixxxii.,  pp.  260-264. 

'  "  De  Forsta  Begreppeu  af  Rorelselarau,"  p.  1866,  164  ;  "  Piii-kortad  Ofversigt  af 
Allmiln  Rorelselara, "  1880,  p.  84. 


248     ELEMENTS    OF   KELLGREN'S  MANUAL   TREATMENT 

Nerve  vibrations  and  frictions  may  be  used  to  determine  : — 
(1)  Whether  pain  is  local  or  reflex  : 
(•2)  The  degree  of  the  motor  response  ; 

(3)  The  degree  of  the  sensory  response; 

(4)  The  degree  of  the  vasomotor  response  ; 

(5)  The  condition  of  efficiency  as  regards  various  reflex  func- 
tions of  nerves,  such  as  vesicomotor,  cardiomotor,  &c. 

In  a  similar  manner  the  same  movements  may  be  used  for 
prognostic  purposes. 

The  use  of  the  sense  of  touch  as  an  aid  to  diagnosis.  This 
method  has  been  systematically  developed  by  Henrik  Kellgren, 
though  up  to  the  present  there  exists  no  literature  on  the  subject. 

The  ability  to  properly  employ  this  method  can  onlj'  be 
acquired  through  years  of  practice  ;  it  cannot  he  acquired  theo- 
retically. Long  experience  is  indispensable,  presupposing  a 
certain  amount  of  general  natural  aptitude  for  applying  Kellgren's 
treatment,  which  latter  gradually  develops  in  every  adminis- 
trator a  great  delicacy  of  touch. 

It  is  exceedingly  difiicult  to  provide  a  description  of  this 
method  which  shall  be  intelligible  to  those  who  have  not  had  the 
opportunity  of  actually  employing  it ;  I  will,  therefore,  limit  myself 
to  the  following  remarks.  When  executing  such  a  manipulation 
as  head  or  stomach  exercise,  a  trained  hand  at  once  recognises  very 
slight  abnormal  fulness,  pulsation,  fluctuation,  heat,  stifiness  of 
muscles,  &c.  But  sometimes,  even  in  the  absence  of  definite 
abnormalities,  the  assistant  is  cognisant  through  his  touch  that 
the  part  under  manipulation  does  not  feel  perfectly  healthy.  This 
part  is  then  treated  until  the  trained  hand  either  feels  that  the 
part  is  once  more  normal,  or  else  that  no  more  can  be  done  for 
it  for  the  time  being. 

It  is  difficult  to  overrate  the  usefulness  of  the  sense  of  touch 
in  this  connection.  It  also  frequently  enables  the  operator  to 
determine  which  parts  of  the  patient  need  special  treatment,  and 
also  how  long  such  parts  should  be  manipulated  ;  and  finally  it  is 
often  successful  where  other  methods  fail  entirely. 


CHAPTER   11. 

GENERAL   PRINCIPLES   IN  THE  APPLICATION    OF 
THE    MANUAL   TREATMENT. 

The  object  of  the  manual  treatment  is  to  replace  pathological 
conditions  by  physiological  ones.'  This  is  effected  by  executing 
movements  in  physiological  harmony  with  the  requirements  of 
the  particular  case,  as  follows — 

I.  Local  treatment  over  the  specially  affected  parts. 

II.  General  treatment,  by  which  is  meant  treatment  of  the 
constitution  as  a  whole. 

The  reasons  for  the  former  are  obvious  enough,  but  the  reasons 
for  the  latter  are  not  so  widely  understood  ;  and  in  fact  the 
modern  practitioners  of  Ling's  system  in  a  great  many  cases  only 
treat  locally.  Treatment  of  the  patient's  constitution  as  a  whole 
should,  however,  always  form  part  of  the  remedial  course,  how- 
ever local  be  the  pathological  condition.  There  are  several 
reasons  for  this  : — 

(1)  Normally  there  are  a  great  many  toxins  and  waste  matters 
in  the  general  circulation,  but  no  harm  results,  as  the  body  by 
means  of  vital  chemical  changes  and  natural  power  of  resistance 
is  able  to  reject  them  ;  but  should  it  become  unable  to  do  so,  then 
disease,  either  general  or  local,  sets  in.  By  treating  the  consti- 
tution, however,  steps  are  taken  towards  restoring  or  retaining 
this  power  of  elimination. 

(2)  Any  local  lesion  will  itself  in  the  course  of  time  become  a 
source  of  production  of  toxins  and  waste  matters  other  than 
those  just  referred  to.  These  new  products  will  tend  to  lower 
the  vitality,  and  should  the  body  fail,  as  it  were,  to  "  rise  to  the 
occasion,"  then  the  constitutional  symptoms  may  become  very 
severe,  and  if  not  checked  the  result  may  be  fatal.     Even  if  the 

'  C/.  Neumann,  "Das  Muskelleben  das  Menschen  in  Beziehung  auf  Heil- 
gymnastik  und  Turnen,"  1855,  p.  21. 


250       ELEMENTS    OF    KELLGREN'S   MANUAL    TREATMENT 

body  is  able  to  throw  off  these  toxins,  &c.,  a  considerable  effort 
will  be  required,  and  in  either  case  the  manual  treatment  will 
materially  assist  the  process  of  elimination. 

(3)  If  there  is  a  tendency  for  waste  products  to  accumulate, 
these  will  tend  to  do  so  in  the  weakest  parts  of  the  body,  i.e., 
those  which  have  the  least  physiological  power  of  resistance  ; 
thus  such  parts  must  be  continually  stimulated  in  order  to  avoid 
their  becoming  secondarily  affected. 

(4)  The  actual  cause  of  the  disease  may  be  overlooked,  should 
general  treatment  be  omitted.  As  an  example  I  may  take  spinal 
curvatures.  These  may  be  due  to  a  tender  or  irritative  con- 
dition of  some  internal  organ,  such  as  an  ovary  or  kidney  ; 
deformities  in  the  vertebrae  will  arise  in  the  course  of  time  from 
the  reflex  contraction  of  muscles  over  these  parts.  These  causes 
are  usually  not  mentioned  in  the  literature  on  spinal  curvatures, ' 
they  are,  however,  very  important  indeed.  To  simply  treat  the 
deformity  without  attacking  the  cause  will,  of  course,  only  yield  a 
very  slightly  beneficial  result,  if  indeed  any  at  all.  The  experi- 
ence of  Henrik  Kellgren  tends  to  show  that  the  cause  of  many 
Puffections  in  peripheral  parts  is  more  often  to  be  found  in  diseases 
of  the  internal  organs  than  is  generally  supposed. 

The  manual  treatment,  local  and  constitutional,  greatly 
inci'eases  the  physiological  power  of  resistance,  both  locally  and 
generally.  This  is  a  very  important  factor  in  the  cure,  especially 
as  the  curative  influence  is  not  purely  external ;  it  is  endeavoured 
to  render  the  patient  himself  the  source  of  remedy.  It  is  of 
paramount  importance  to  develop  the  active  elements  in  the 
patient,  however  weak  and  feeble  at  first,  by  getting  him  to  use 
his  own  muscles,  his  own  nerves,  his  own  brain.  The  first  sign 
of  his  beginning  to  use  these  is  the  first  sign  of  returning  power 
of  resistance  to  disease  ;  it  must  be  remembered  that  a  cure  doe.s 
not  commence  with  the  first  application  of  treatment  (external 
assistance),  but  with  the  moment  that  the  patient's  body  begins 
actively  to  lend  support  towards  the  result  that  the  treatment  is 
striving  to  obtain  (internal  co-operation) . 


'  Wide,  who  is  considered  a  specialist  ou  spinal  curvatures,  does  not  mention 
them  in  his  handbooks. 


CHAPTER    III. 

SPECIFIC   INFECTIOUS   DISEASES.      . 

The  experience  of  the  Lino;  school  has  tended  to  show  that 
acute  fevers,  whether  specific  infectious  or  otherwise,  do  not 
enter  into  the  sphere  of  medical  gymnastics.  There  have  been  a 
few  successful  efforts,  such  as  Branting's  ^  case  of  acute  pneu- 
monia, but  on  the  whole  the  Ling  school  condemns  attempts  to 
apply  gymnastic  manipulations  to  such  conditions  (c/.  P.  H.  Ling,- 
Georgii'').  Wide  '  is,  of  course,  opposed  to  gymnastic  treatment 
for  acute  specific  infectious  diseases. 

In  applying  Kellgren's  treatment  to  acute  specific  infectious 
diseases  the  following  are  the  objects  in  view : — 

(A)  During  the  Acute  Stage. 

I. — To  improve  the  local  condition  or  conditions,  and  thereby 
raise  the  local  power  of  resistance.     This  is  effected  by : — 

(1)  Promoting  the  circulation  both  of  the  blood  and  lympb, 
and  causing  vaso-constriction  of  over-dilated  arteries,  by  means 
of  passive  manipulations  such  as  vibrations,  shakings,  frictions, 
nerve  frictions,  &c.,  and  occasionally  by  means  of  passive  move- 
ments of  joints. 

(2)  Raising  the  nervous  functionability  by  stimulating  the 
nerve  trunks  by  nerve  frictions. 

II. — To  diminish  the  constitutional  disturbance  by  raising  the 
power  of  resistance  of  the  body  as  a  whole,  and  thus  also  presum- 
ably aiding  in  the  process  of   the   natural  antitoxin  formation. 


'  See  p.  311. 

-  "  Gymnastikeus  AUmanna  Grander  "  (1834)  1840,  pp.  180,  181. 

»"  Kinetic  Jottings,"  1880,  pp.  166,  206. 

'"  Handbok  i  Mediciusk  Gymuastik,"  1896,  p.  149;  "Handbook  of  Medical 
Gymnastics,"  1899,  p.  148;  "Handbok  i  Jledicinsk  och  Ortopedisk  Gymuastik," 
1902,  p.  189  ;  "  Handbook  of  Medical  and  Orthopaedic  Gymnastics,"  1903,  p.  1.5G. 


252    ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

This  is  effected  l)y  means  of  the  so-called  "  general  treatment  for 
fever,  "  which  is  executed  so  as  to  :— 

(1)  Diminish  cerebral  excitement ; 

(2)  Stimulate  the  nervous  system  as  a  whole ; 
(8)  Quiet  the  circulatory  disturbances  ; 

(4)  Stimulate  the  organs  that  bring  nutrient  matter  to  the 
l.ndy; 

(5)  Stimulate  the  assimilatory  organs  ; 
(())   Stimulate  the  excretory  organs ; 
(7)   Stimulate  the  spleen. 

This  so-called  "  general  treatment  for  fever  "   comprises  : — 

(1)  Head  exercise ; 

(2)  Spinal  nerve  frictions,  especially  cervical  ; 

(3)  Heart  vibration  or  shaking  ; 

(4)  Side  shaking,  and  inducing  the  patient  to  take  a  few  deep 
respirations ; 

(5)  Stomach  exercise  ; 

(6)  Kidney  vibration  or  friction  ; 

(7)  Spleen  vibration  or  friction  ; 

(8)  Vibration  or  shaking  over  the  bladder  (usually). 
Begulations  as  to  diet  and  rest  in  bed. — I  have  never  imposed 

the  slightest  restriction  on  diet,  but,  on  the  contrary,  have  always 
allowed  my  patients  (when  I  have  had  the  case  in  hand  from  the 
beginning)  to  act  in  this  respect  exactly  as  they  wished,  and  I 
have  never  had  the  slightest  cause  to  regret  this  procedure.  It 
seems  that  Kellgren's  treatment  greatly  assists  the  powers  of 
assimilation,  and  this  is  a  powerful  factor  in  keeping  up  the 
patient's  strength  and  cutting  short  the  disease,  &c.  I  have  like- 
wise almost  invariably  allowed  my  patients  to  get  up  if  they 
wished  to,  provided  that  the  room  was  warm  and  they  were  kept 
from  draughts,  except  in  cases  accompanied  by  delirium,  when  I 
have  endeavoured  to  keep  my  patients  quiet  in  bed.  I  must  not 
be  misiinderstood  in  this  respect ;  the  profession  must  not  believe 
that  I  make  my  patients  eat  heartily  and  make  them  get  up;  I 
merely  leave  them  to  act  on  the  dictates  of  Nature,  whom  I  regard 
as  the  best  judge  under  the  circumstances. 

I  consider  compulsory  prolonged  rest  in  bed  a  powerful  factor 
in  reducing  the  vitality  as  a  whole,  in  aiding  general  venous 
stasis,  and  in  promoting  hypostatic  congestion,  especially  of  the 
kidneys,  all  of  which  are  the  very  conditions  to  be  avoided. 


SPECIFIC     INFECTIOUS    DISEASES  253 

(B)    During    the    Convalescent    Stage. 

The  treatment  during  the  convalescent  stage,  having  more  or 
less  different  objects  in  view,  is  different  from  that  administered 
during  the  acute  stage.  It  may  be  conveniently  termed  "  general 
treatment  for  convalescence."     Its  objects  are  as  follows  : — 

(1)  To  stimulate  the  organs  or  parts  that  have  been  the  seat 
of  any  local  lesion. 

(2)  To  improve  the  constitution  as  a  whole  by  means  of 
circulatory  and  respiratory  exercises,  movements  to  stimulate 
the  assimilatory  and  excretory  organs,  and  stimulatory  nerve 
manipulations.  Purely  active  and  duplicate  exercises  should  be 
given  as  soon  as  possible. 

From  a  clinical  point  of  view  the  following  are  the  chief  results 
obtainable  in  the  majority  of  instances  by  applying  Kellgren's 
treatment  to  cases  of  fever  :  — 

(1)  Delirium  is  prevented,  or  removed  if  present. 

(2)  The  general  condition  of  the  patient  is  improved  there  and 
hen,  nearly  always  from  a  subjective,  and  frequently  from  an 

objective  point  of  view. 

(3)  Pyretic  and  hyperpyretic  temperatures  are  lowered,  some- 
times at  once,  sometimes  an  hour  or  so  after  the  conclusion  of 
the  treatment. 

(4)  The  progi'ess  of  the  disease  is  cut  short. 

(5)  Complications  are  reduced  to  a  minimum. 

(6)  Convalescence  is  hastened. 

(7)  Sequelae  are  prevented. 

(8)  The  cure  is  absolute  and  permanent ;  in  some  cases  the 
patients  will  continue  in  much  better  health  after  the  disease  has 
passed  than  they  had  enjoyed  for  many  months  preceding.  (See 
appendix.) 

In  any  of  the  fever  charts  appended,  if  two  points  are  marked 
in  the  same  temperature  column,  they  represent  the  temperature 
immediately  before  and  immediately  after  the  treatment.  Two 
figures  in  the  pulse  column  mean  the  same  as  regards  the  pulse. 

Typhoid  Fever. 

C.  G.,  male,  aged  24,  came  under  the  manual  treatment  on 
March  30,  1902. 

Previous  history. — Quite  good. 


254     ELEMENTS   OF   KELLCREN'S   MANUAL    TREATMENT 

History  of  present  illness. — He  believed  he  caught  a  chill  on 
March  20,  which  manifested  itself  in  general  weakness,  fatigue, 
and  headache.  His  condition  remained  unchanged  during  the 
ensuing  week ;  during  this  time,  however,  he  did  not  feel  so 
imwell  as  to  be  obliged  to  cease  work  at  the  Huskvarna  iron 
factory.  During  the  evening  of  March  28  he  was  suddenly  seized 
with  pains  in  the  legs  and  chest,  which  were  so  severe  that  he 
had  at  once  to  go  to  bed.  A  masseur  was  called  in,  who 
administered  massage  on  the  painful  areas  without  improving 
matters.  March  29. — Morning.  Condition  about  the  same ; 
patient  in  bed  all  day.  More  massage  administered.  Evening. 
Condition  worse  ;  pain  chiefly  in  abdomen.  "  Abdominal 
massage  "  made  him  still  worse.  March  30. — Morning.  During 
the  night  patient  felt  very  ill ;  had  violent  attacks  of  abdominal 
pain,  and  slept  very  badly.  No  motion  since  March  27.  An 
attempt  to  administer  "  abdominal  massage "  failed  on  account 
of  the  pain  induced,  and  I  was  called  in. 

Examination. — March  30,  2  p.m.  The  patient  looked  feverish, 
and  was  lying  in  bed  with  his  legs  drawn  up.  He  complained 
of  continued  severe  pain  in  the  right  side  of  the  abdomen ; 
any  attempt  at  movement  or  at  straightening  his  legs  made 
it  worse.  Occasionally  there  were  acute  exacerbations  of  the 
pain.  The  appetite  was  very  poor ;  only  bread  and  butter 
and  milk  had  been  consumed  during  the  last  three  days.  There 
was  a  good  deal  of  eructation,  but  no  vomiting  ;  and  no  motion 
had  taken  place  that  day.  The  respiration  was  entirely  thoracic  ; 
any  attempt  to  use  the  abdomen  in  breathing  caused  severe 
stabbing  pains  in  that  region.  The  anterior  abdominal  muscles 
of  the  right  side  were  firmly  contracted ;  those  of  the  left  side 
partially  contracted.  Great  tenderness  to  pressure  existed  on  the 
right  side,  some  also  on  the  left.  Deep  palpation  of  the  abdomen 
was  impossible.  The  patient  had  his  first  and  only  rigor  the 
same  morning.  (For  temperature  and  pulse  see  separate  chart, 
fig.  90.     Cf.  effect  of  treatment  with  ordinary  records.) 

After  treatment  the  patient  could  stretch  his  legs  without 
discomfort,  and  the  pain  in  abdomen  was  lessened ;  he  could  also 
to  a  slight  extent  use  his  abdomen  for  respiration  without  extra 
pain. 

Evening.  Condition  about  the  same.  No  motion.  Treatment 
repeated. 


SPECIFIC     INFECTIOUS    DISEASES  255 

Treatment  henceforth  administered  twice  a  day. 

March  31. — Morning.  Patient  had  slept  fairly  well.  Pain 
less.      Patient  felt  like  having  a  motion,  but  failed  to  induce  one. 

Evening.  Motion,  normal  in  appearance,  at  2  p.m. ;  there- 
after a  good  deal  of  pain  in  the  abdomen,  which,  however,  soon 
passed  off.  Patient  sat  up  most  of  the  afternoon.  General 
condition  otherwise  about  the  same. 

April  1. — Morning.  After  breakfast  (8  a.m.)  some  severe  pain, 
which,  however,  soon  disappeared.  11  a.m.  Pain  in  abdomen 
much  less  than  yesterday  ;  contraction  of  abdominal  muscles 
present,  but  considerably  diminished  by  treatment.  Deep  pal- 
pation of  the  abdomen  was  possible  for  the  first  time,  and  by 
its   means   I  could    feel    that   the   risht   iliac   and   right    lumbar 


MARCH 

APRIL 

DATE 

30   31  ,    1     ,  2      3    i  4  ;  5  1  6    i  7-    1  a   1  9      10     11.12     13    14    13  !  16    IT     18     19    20    21     22  23  24   25  25 1 

TIME 

<  EM   E 

J   EM  E,M   E:»  E 

i  E 

H   EM    E.H   E|M   E:m   EM   E 

A   EM    E 

H    EM   E'M   EM    EH    EM   EH    EM    EM   EM    EM    EM    EM    E| 

F" 

Moi 

th 

A 

/ 

\i 

\/ 

A 

A 

/ 

^^ 

1 

^J 

^ 

/ 

1 

s/ 

" 

\ 

/ 

S,' 

K-S 

— 

- 

V 

/ 

\ 

1 

PULSE 

100    ;8a    84    86    .64.    BZ    90  105    100    105 
90;    36    871    81     86    86  100   102    100    90 

78    84    74     74     84    86    68    iSl     i8,     ,68 
84    76    72     71.    68     67    78    74-     76    60 

62 

BOWELS 

0|ll0|l|O|lll|l]O|l!3l34i2ll|2i2|2|2|2 

1    1    1 

1 

2 

0 

2 : 1 

1 

regions  were  filled  up  by  a  lai-ge,  softish,  boggy  mass,  very 
tender  to  touch.  On  executing  vibrations  over  it,  gurgling 
sounds  were  heard  and  felt. 

Evening.     About  the  same.     No  motion  during  the  day. 

April  2.- -Motion,  apparently  normal,  during  the  morning; 
after  it  some  pain.  Appetite  better ;  patient,  who  had  been 
living  for  the  last  week  on  bread,  butter,  and  milk,  ate  some  fish. 

April  3. — Contraction  of  abdominal  muscles  still  less. 
Appetite  better.  Patient  up  during  the  greater  part  of  the  day 
in  an  arm-chair  ;  walked  about  at  intervals.  Pulse  markedly 
dicrotic  from  to-day  onwards  during  the  following  week. 

April  4. — Motion,  apparently  normal,  during  the  morning. 
The    large  mass  in  the  abdomen   was  smaller  and  less  tender. 


256     ELEMENTS   OF    KELLGREN'S    MANUAL    TREATMENT 

Patient  up  all  day.     Appetite,   however,   not    quite    so  good   as 
during  the  previous  day. 

April  5. — Eiise  of  temperature.  Patient  rather  worse,  but 
able  to  sit  up  all  day  in  an  arm-chair.  In  the  evening  I  was  told 
that  patient  had  had  a  foul-smelling,  yellowish-green  diarrhoeic 
motion,  after  which  there  was  very  much  abdominal  pain.  I  did 
not  see  the  motion,  as  it  was  thrown  away  at  once. 

April  6. — Morning.  Further  rise  of  temperature.  Patient 
looked  and  felt  worse.  He  was  able  to  sit  up  in  an  arm-chair 
until  '2  p.m.,  but  then  felt  so  ill  as  to  be  obliged  to  go  to  bed. 
3  p.m.  Pain  in  abdomen  worse  ;  more  contraction  of  abdominal 
muscles.     At  5  p.m.  attack  of  epistaxis. 

Evening.  Condition  still  worse.  Diagnosis  of  typhoid  fever 
rendered  positive.  A  culture  taken  from  the  next  motion 
revealed  the  characteristics  of  typhoid  bacilli,  and  not  those  of 
bacillus  coli  communis.  Patient  apathetic  ;  did  not  speak  unless 
spoken  to  first ;  answered  questions  slowly  and  sadly.  Cheeks 
flushed,  eyes  bright ;  typhoidy  appearance  of  face.  Pupils  dilated. 
Tongue  coated,  redness  of  fauces.  He  "  lies  low  in  bed,"  con- 
stantly on  his  back.  More  pain  and  tenderness  in  abdomen, 
specially  in  the  right  iliac  and  right  lumbar  regions ;  marked 
swelling  of  the  right  side  of  the  abdomen.  Spleen  and  liver  not 
enlarged.  Urine  highly  coloured,  scanty.  Pulse  dicrotic ;  no 
weakness  of  first  cardiac  sound.  Lungs  normal.  No  subsultus 
tendinum. 

During  the  ensuing  fortnight  I  tested  the  urine  twice  daily 
for  albumen  (nitric  acid  in  the  cold),  but  never  found  any,  and 
auscultated  the  heart,  but  never  found  weakness  or  muffling  of 
the  first  sound.  I  likewise  tested  for  enlargement  of  the  liver  and 
spleen,  but  could  never  detect  either.  The  patient's  relatives 
were  instructed  henceforth  to  examine  all  motions  for  blood  or 
tar-like  substance,  &c.,  but  they  invariably  reported  that  none 
was  ever  found. 

April  7. — Morning.  During  the  night  another  motion  similar 
to  the  previous  one,  and  after  it  much  abdominal  pain.  Patient 
had  slept  very  badly.  A  good  deal  of  eructation,  as  also  during 
the  previous  day.     Eight  side  of  abdomen  softer.     No  rash. 

Evening.  Temperature  lower  and  general  condition  better 
than  during  the  previous  evening. 

April  8. — Morning.    Patient  had  slept  better.    Another  attack 


SPECIFIC    INFECTIOUS    DISEASES  257 

of  epistaxis  at  8  a.m.     Abdomen  not  so  swollen  and  less  tender. 
Tongue  tremulous.     Marked  typhoid  odour. 

Evening.  Patient  distinctly  better.  Temperature  once  more 
lower.  Patient  had  been  lying  on  his  side  during  part  of  the 
day.  Motion  this  afternoon  (first  time  since  evening  of  April  6) 
similar  to  the  last  one,  but  no  pain  after  it.  Patient  had  con- 
sumed nothing  but  milk  since  April  5.     No  rash. 

April  9. — Morning.  Peasoup-like  motion  during  the  night. 
Patient  had  slept  very  well.  Temperature  normal.  Patient 
looking  more  lively ;  spoke  without  being  spoken  to  first,  and 
laughed  for  the  first  time  since  the  commencement  of  his  illness. 
Less  pain  in  abdomen,  very  little  contraction  of  abdominal 
muscles. 

Evening.  Two  peasoup-like  motions  since  the  morning. 
Urine  clear  and  of  normal  colour.  Two  rose-coloured  spots  on 
the  abdomen.     Patient  had  consumed  some  eggs  and  milk. 

April  10.— Mornmg.  Temperature  (both  morning  and  even- 
ing) about  normal  from  now  onwards.  Patient  sat  up  in  bed 
most  of  the  day  (first  time  since  April  6).  One  peasoup-like 
motion  during  the  morning.  Breakfast,  milk  and  eggs  ;  dinner, 
fish  ;    supper,  milk,  bread  and  butter. 

Evening.  Two  more  motions  during  the  day,  same  colour, 
but  not  so  loose  as  the  morning  one.  Less  tenderness  in 
abdomen. 

April  11. — Morning.  One  motion  at  5  a.m.,  darker  in  colour, 
but  diarrhceic ;  another  at  7  a.m.,  same  colour  as  last,  but  of 
ordinary  consistency. 

Evening.  Patient  got  up  and  sat  in  an  arm-chair  for  an  hour 
this  afternoon.  Rash  disappeared.  Another  diarrhceic  motion 
during  the  evening.     Diet  same  as  during  the  previous  day. 

April  12. — Morning.  Yellowish  somewhat  diarrhceic  motion 
during  the  morning.  BVeakfast,  milk,  one  egg,  a  little  fish, 
bread  and  butter. 

Evening.  Patient  had  sat  in  an  arm-chair  most  of  the  day, 
and  had  been  walking  up  and  down  in  his  room  at  intervals.  No 
pain  in  the  abdomen,  but  still  some  tenderness  to  deep  pressure, 
and  a  sense  of  fulness  on  palpation.  I  administered  a  fairly 
gentle  stomach  exercise  to-day  for  the  first  time.  Dinner,  soup 
and  milk  ;  supper,  fish  and  milk. 

April  I'd. — Only  one  motion  to-day,  light  brown  and  diarrhceic. 
17 


258     ELEMENTS    01-    KELLGREN'S    MANUAL   TREATMENT 

Eructations,  which  had  been  persisting  since  April  (5,  almost 
disappeared.  Breakfast,  same  as  the  last,  with  the  addition  of 
a  little  coffee  ;  dinner,  a  small  piece  of  mutton  ;  supper,  same  as 
the  last. 

April  14. — Apathj'  entirely  disappeared  :  appearance  of  face 
normal.  Two  motions  during  the  daj',  both  of  normal  consistenc}-, 
although  light  in  colour.     Mutton  both  for  breakfast  and  dinner. 

April  15. — Typhoid  odour  gone.  Two  motions,  one  normal  as 
regards  colour  and  consistency,  the  other  lighter  in  colour  and 
looser.  Breakfast,  two  eggs,  pancakes,  milk,  coffee ;  dinner, 
soup,  fish ;  supper,  fish,  one  egg,  bread  and  butter. 

April  16. — Two  motions  just  like  those  of  the  previous  day. 
Breakfast,  two  eggs,  milk,  coffee;  dinner,  fish,  pork  chop  and 
potatoes  ;  supper,  fish,  bread  and  butter,  milk.  Patient  went  out 
for  half  an  hour's  walk. 

April  17. — Two  apparently  normal  motions.  From  to-day 
onwards  the  motions  presented  no  abnormality  as  far  as  could  be 
detected  by  inspection  and  odour.  Patient  took  an  hour's  walk 
during  the  morning  and  half  an  hour's  walk  in  the  afternoon. 

April  18. — Patient  was  out  walkmg  altogether  for  three  hours. 
Two  motions. 

April  19. — Patient  walked  to  my  house  for  treatment  (distance 
one  mile).  Treatment  once  a  day  henceforth.  Beyond  a  slight 
sense  of  resistance  in  the  right  half  of  the  abdomen  and  general 
weakness  patient  was  normal.  Several  active  movements  were 
performed  from  to-day  onwards,  including  sitting  trunk  extension 
and  flexion,  PA,  which,  however,  the  patient  could  not  execute 
unaided.  One  motion.  Patient  was  out  walking  altogether  for 
five  hours. 

April  20.  — Loin  lean  stride  standing  alternate  rotation,  AE, 
ringing,  PP,  given  from  to-day  onwards.     One  motion. 

April  '21. — Patient  daily  getting  stronger.     One  motion. 

April  22. — Two  motions. 

April  23. — ^No  motion. 

April  24. — Two  motions. 

April  25. — One  motion. 

April  26.^ — One  motion.  Patient  able  lo-day  to  do  sitting 
trunk  extension  and  flexion,  PA,  without  help. 

April  27. — lS!ot  treated.     Two  motions. 

April  28. — One  motion.     Patient  weighed  himself  to-day  and 


SPECIFIC    INFECTIOUS    DISEASES  259 

found  that  he  weighed  64  kilos,  as  compared  with  68  kilos,  in  the 
l)egiuning  of  March. 

April  29,  30. — One  motion. 

May  1. — Not  treated.     One  motion. 

May  2. — One  motion. 

May  3. — One  motion.  Patient  said  that  he  felt  quite  as 
strong  as  before  his  illness.     Was  treated  for  the  last  time. 

May  5. — Patient  returned  to  his  usual  work  at  the  factory. 

Treatment. 

Head  exercise,  spinal  nerve  frictions,  vibrations  over  the  right 
side  of  the  abdomen  given  in  a  somewhat  upward  direction, 
stomach  exercise  confined  to  the  left  side  of  the  abdomen,  side 
shaking,  and  patient  had  to  attempt  abdominal  respiration ; 
spleen  and  kidney  frictions  and  frictions  over  the  lateral  abdomi- 
nal nerves.  As  improvement  set  in  the  vibrations  were  executed 
more  energetically,  and  with  greater  firmness  and  pressure  ;  and 
later  on,  when  the  reflex  contraction  of  the  abdominal  muscles 
permitted  it,  the  stomach  exercise  was  performed  on  the  right 
half  of  the  abdomen  as  well.  During  convalescence  some  active 
exercises  for  the  abdomen  were  added  (see  above). 

No  restrictions  were  placed  on  the  diet  or  on  the  length  of 
time  that  the  patient  had  to  remain  in  lied ;  lie  was  allowed 
absolute  freedom  in  both  respects. 

Whooping  Cough. 

A.  W.,  female,  aged  4,  came  under  the  manual  treatment  on 
October  16,  1901. 

Previous  history. — Patient  had  been  quite  strong  and  healthy 
until  seven  months  previously  when  she  had  an  attack  of  diph- 
theria, from  the  effects  of  which  she  had  never  completely  re- 
covered. 

History  of  present  illness. — Patient  had  often  plajed  during 
the  summer  with  several  children  about  her  own  age,  three  of 
whom  developed  whooping  cough  about  the  middle  of  September. 
A  week  later  she  began  to  cough  a  little,  but  her  mother  took 
little  notice  of  this,  thinking  that  she  suffered  merely  from  an 
ordinary  cold.  After  a  week,  however,  the  paroxysmal  stage  of 
whooping  cough  set  in.  Patient  had  typical  attacks  of  whoop- 
ing, which  sometimes  came  spontaneously  and  were  sometimes 


26o     ELEAIENTS  OF   KELLGREN'S    MAWAL    TREATMENT 

induced  by  cryiug  or  emotion  ;  they  frightened  her  considerably, 
and  during  their  progress  she  became  blue  in  the  face,  with  start- 
ing of  the  eyes.  On  occasions  vomiting  immediately  followed  the 
cessation  of  the  whoop.  The  average  of  attacks  had  been  fairly 
constant  during  the  past  fortnight ;  some  three  or  four  took  place 
during  each  day  and  from  ten  to  twenty  during  each  night. 
Catarrhal  condition  of  the  bronchi  was  evident  on  auscultation. 
There  was  no  fever.  Treatment  administered  once  a  day  hence- 
forth. 

October  17. — Patient  had  twelve  attacks  during  the  night, 
and  none  at  all  during  the  day. 

October  18. — Patient  coughed  a  good  deal  during  the  night, 
but  there  was  no  whooping. 

October  21. — One  whoop  during  the  day,  after  which  no  more 
occurred.     Patient  slept  all  night. 

November  '21. — Bronchi  normal.     No  cough. 

December  6. — Treatment  continued  daily  to  this  date,  then 
stopped.  Patient  had  not  coughed  at  all  since  about  November 
'■21. 

Treatmriif. 

Chest  vibration,  side  shaking,  shaking  over  the  bladder  and 
in  the  subcostal  angle,  inducing  patient  to  attempt  several  con- 
secutive deep  respirations,  spinal  nerve  frictions,  specially  inter- 
scapular, vibrations  on  the  medulla,  stomach  exercise.  Later 
on  (about  November  12)  chest  clapping  was  added. 

Measles  following  on  Whooping  Cough. 

E.  P.,  female,  aged  17  months,  came  under  the  manual  treat- 
ment on  August  30,  1902. 

Previous  history. — Quite  good. 

History  of  present  illness.— Pa,tient  had  been  suffering  for  the 
previous  three  weeks  from  whooping  cough  in  the  paroxysmal 
stage,  the  malady  having  been  most  severe  during  the  third  week. 
She  experienced  eight  to  twelve  attacks  of  whooping  during  the 
day,  and  several  during  the  night.  About  August  26  her  parents 
noticed  that  she  had  a  continual  loose  cough,  and  thought  that 
she  must  have  caught  cold.  August  27,  patient  worse.  August 
'IH,  patient  still  worse  and  alHicted  with  watering  of  the  eyes  and 
running    from    the    nose;    parents    thought    she    was    feverisli. 


SPECIFIC    INFECTIOUS    DISEASES  261 

August  29,  patient  still  worse,  parents  could  hear  loud  bubbling 
sounds  in  the  chest;  during  the  evening  they  noticed  redness  of 
the  skin.  August  30,  chest  symptoms  worse,  and  measly  rash 
fully  developed.  I  was  called  in  during  the  evening  of  the  same 
day. 

Exatni/iation. —  Patient  in  bed,  very  restless,  cryuig  continually 
and  perspiring  freely  ;  had  eaten  nothing  during  the  day.  Much 
lachryniation  and  nasal  coryza.  Typical  measles  rash  over  the 
whole  body.  Alse  nasi  working  with  respiration,  which  was 
laboured ;  some  cyanosis.  Loud  coarse  rales  heard  at  some 
distance  from  patient  and  on  auscultation  over  both  lungs  ;  no 
percussion  dullness.  Patient  had  been  suffering  from  diarrhoea 
to  the  extent  of  four  or  five  motions  daily,  but  her  mother 
informed  me  that  the  child  was  just  cutting  two  teeth  and  that 
she  always  suffered  from  diarrhoea  on  such  occasions.  Tempera- 
ture 1022'",  respiration  88,  pulse  186  before  treatment ;  101'3°, 
64  and  160  respectively  after  treatment.  Patient  went  to  sleep. 
Treatment  twice  a  day  henceforth. 

August  31. — Morning.  Patient  had  had  a  fairly  good  night, 
and  during  the  morning  had  been  sitting  up  and  looking  about, 
which  she  did  not  do  at  all  during  the  previous  day.  Not  so 
restless  or  irritable,  less  lachrymation,  rash  fading.  Temperature 
1016°,  respiration  .58,  pulse  176  before  treatment ;  101"3',  67,  16.5 
respectively  after  treatment,  .liter  I  left  patient  consumed  some 
milk. 

Evening.  Patient  better  ;  had  been  sitting  up  during  most  of 
the  day  and  had  consumed  a  fair  amount  of  milk.  Only  three 
diarrhoeic  motions.  Rash  still  more  faded;  less  lachrymation  and 
coryza,  and  not  so  many  rales  in  the  chest.  Temperature  102°, 
respiration  84,  pulse  166  before  treatment  ;  101'8°,  80  and  160 
respectively  after  treatment. 

September  1. — Morning.  Condition  of  patient  slightly  im- 
proved. Temperature  100'6°,  respiration  88,  pulse  160.  Desqua- 
mation commenced. 

Evening.  Patient  very  irritable,  and  cried  during  the  whole 
of  the  treatment,  so  I  did  not  count  her  pulse  or  respiration. 
Temperature  100"8°. 

September  2. — Morning.  Patient  had  perspired  very  much 
during  the  first  half  of  the  night,  and  then  went  to  sleep.  On 
awakmg,  much  better ;    sat    up  during  the  greater  part   of   the 


262     ELEMENTS  OF   KELLGREN'S   MANUAL    TREATMENT 

luonmig.  Appetite  poor  however ;  diarrhoea  still  the  same  as 
on  August  31.  Rash  faint.  Lungs  clearing  up.  Temperature 
98"6°,  respiration  (?2,  pulse  150. 

During  the  course  of  the  day  patient  coughed  very  much,  but 
was  free  from  whooping. 

Evening.     Temperature  100',  respiration  72,  pulse  150. 

September  3. — Morning.  Patient  much  better ;  appetite 
normal  again ;  diarrhoea  less,  liash  hardly  visible  on  face.  A 
few  fine  crepitations  in  the  lungs  were  the  only  abnormal  sounds 
to  be  heard.    Temperature  99'7%  respiration  48,  pulse  132. 

Evening.  Some  return  of  the  attacks  of  whooping  during 
the  day ;  otherwise  better.  Temperature  99"1°,  respiration  50, 
pulse  136. 

September  4. — Treatment  once  a  day  henceforth,  each  morn- 
ing. Patient  stronger ;  less  cough.  Lungs  almost  normal. 
Temperature  98'8°. 

September  5. — No  more  whooping.  Lungs  normal.  Tem- 
perature 37°.     Still  some  diarrhoea. 

September  6. — Temperature  984°.  Patient  had  not  passed 
urine  for  eighteen  hours  ;  micturition,  however,  took  place  imme- 
diately when  I  administered  shaking  over  the  bladder.  Diarrhoea 
ceased. 

September  7. — Some  return  of  attacks  of  coughing,  resem- 
bling whooping  cough  to  some  extent. 

September  9. — Cough  less. 

September  11. — Slight  cough  left,  no  resemblance  at  all  to 
whooping  cough.  Lungs  normal.  Rest  of  patient  normal. 
Treatment  for  the  last  time. 

(The  temperatures  were  all  taken  j;e/-  rectum.) 

Treat  iiiriit. 

During  the  acute  stage  : — Head  exercise,  including  vibrations 
on  the  medulla,  fronto-nasal  running  vibration ;  chest  vibration, 
side  shaking ;  spinal  nerve  frictions,  specially  interscapular : 
stomach  exercise,  liver,  spleen  and  kidney  frictions,  shaking  over 
the  bladder.  During  the  convalescent  stage : — Chest  vibration, 
side  shaking ;  spinal  nerve  frictions,  especially  interscapular, 
forwards  lying  back  exercise,  stomach  exercise,  spleen  and  kidney 
frictions,  shaking  over  the  bladder;  double  arm  rolling ;  leg  rolling. 


SPECIFIC    INFECTIOUS    DISEASES  263 

Measles. 

H.  L.,  male,  aged  8i,  came  under  the  manual  treatment  on 
August  6,  1902. 

Previous  history. — At  the  age  of  about  nine  months  it  was 
noticed  that  he  had  a  cyst  in  his  neck  near  the  clavicular 
insertion  of  the  left  sterno-mastoid,  and  this  caused  a  chronic 
irritative  croupy-like  cough  every  winter  since  his  birth. 
During  the  month  previous  to  his  attack  of  measles  patient  had 
had  large  numbers  of  furuncles  appearing  in  crops  at  intervals  ; 
these  discharged  pus  and  itched  so  that  he  was  driven  to  scratch 
them.  When  I  first  saw  patient  he  had  eighteen  of  these 
furuncles  situated  on  his  trunk  and  arms,  each  of  which  (together 
with  its  margin)  was  about  the  size  of  a  threepenny  bit. 

History  of  present  illness. — On  August  B  the  parents  noticed 
that  he  had  a  slight  cough,  which  on  August  4  was  worse,  and 
was  accompanied  by  an  appearance  of  obvious  ill-health.  During 
the  afternoon  of  that  day  patient  was  feverish,  and  the  cough 
still  worse  ;  in  addition  there  was  running  at.  the  nose  and  redness 
of  the  eyes,  but  no  vomiting.  August  5. — Aggravation  of  all  the 
symptoms  ;  during  the  evening  the  parents  noticed  a  commenc- 
ing rash.  During  the  ensuing  night  patient  slept  very  little. 
On  the  morning  of  August  6  a  measly  rash  had  developed,  and  I 
was  sent  for.  Owing  to  pressure  of  work  I  was  unable  to  attend 
the  patient  until  8  p.m. 

Ejiammation. — Patient  very  irritable,  restless,  and  crymg 
continuously ;  suffering  from  great  redness  of  the  eyes  and  con- 
tinued running  from  the  nose.  Typical  measly  rash  over  the 
whole  body,  most  marked  on  the  face.  Signs  of  acute  diffuse 
bronchitis  with  diffuse  rales,  the  latter  audible  at  a  distance  of 
some  feet.  Temperature  102-6°,  pulse  154.  After  treatment 
patient  was  much  less  irritable  and  restless  (this  happened  after 
every  treatment  in  the  fever  stage),  and  was  able  to  look  at  a 
picture-book.  Temperature  101"1°,  pulse  144.  Hal f-an-hour  after- 
wards a  normal  motion  took  place. 

August  7. — Morning.  Patient  had  slept  very  little.  General 
condition  better,  eyes  less  red,  and  less  discharge  from  nose. 
Temperature  99';j°,  pulse  160.  After  treatment  he  dressed  and 
was  up  for  an  hour,  after  which  he  lay  down  again  for  the  rest 
of  the  day,  occasionally,  however,  getting  up  and  walking  about 
for  a  few  minutes. 


264     ELEMENTS  OF   KELLGREN'S   MANUAL    TREATMENT 

Evening.  Patient  had  eaten  nothing  during  the  day  except 
two  small  biscuits,  and  was  very  irritable  and  restless.  Hash 
quite  out,  except  on  hands.  Temperature  10'2-6°,  pulse  165  ;  after 
treatment  102°  and  IGO  respectively. 

August  8. — Morning.  Patient  had  slept  very  little,  and  had 
taken  a  little  milk  for  breakfast.  Eyes  less  red;  slight  de- 
squamation on  cheeks.  Temperature  98'3°,  pulse  120.  After 
treatment  patient  was  up  for  two  hours,  and  spent  the  rest  of 
the  da}'  alternately  in  lying  down  and  getting  up  and  walking 
about. 

Evening.  No  motion  during  the  day.  Patient  had  eaten 
nothing  since  breakfast ;  was  very  irritable  and  crying  con- 
tinuously. Eyes  no  longer  red  ;  very  little  discharge  from  nose. 
Rash  more  marked  on  hands,  but  fading  on  face  and  legs. 
Temperature  103'1°,  pulse  156  ;  after  treatment  102"2°  and  150 
respectively. 

August  9. — Crisis  during  the  night ;  at  about  4  a.m.  profuse 
sweating,  after  which  patient  fell  sound  asleep ;  on  awaking 
(at  8  a.m.)  better  in  every  respect.  Took  milk,  bread  and  butter 
for  breakfast ;  normal  motion  followed. 

11  a.m.  Patient  up  and  walking  about ;  much  more  cheerful, 
and  hardly  irritable  at  all.  Rash  fading  away  rapidly  ;  desquama- 
tion on  rest  of  face  and  trunk  ;  cough  much  less ;  lungs  clearing 
up.  Temperature  968°,  pulse  120.  Treatment  only  once  a  day 
henceforth. 

At  2  p.m.  patient  ate  an  egg,  and  then  slept  until  8  p.m. 

August  10. — Patient  had  slept  well  the  whole  night.  Appetite 
still  poor.     Desquamation  proceeding  on  arms  and  legs. 

August  11. — Lungs  quite  cleared  up.  No  expectoration  from 
bronchi. 

August  12. — No  more  desquamation  visible.  Patient  went  out 
for  a  walk  of  ten  minutes. 

August  13. — Patient  very  well  ;  appetite  normal.  Furuncles, 
which  had  been  healing  rapidly  since  the  crisis,  now  represented 
by  pink  spots. 

August  17. ■ — No  treatment. 

August  18. — Patient  walked  to  my  villa  and  back  for  treat- 
ment (distance  three-quarters  of  a  mile  each  way). 

August  22. — Normal  motion  every  day  since  the  10th.  Patient 
quite  well  and  strong.  Scars  of  the  furuncles  light  pink  in  colour. 
Treatment  for  the  last  time. 


SPECIFIC    INFECTIOUS     DISEASES  265 

(The  temperatures  were  all  taken  jjer  rectum.) 
Treattnent. 

During  the  acute  stage : — Head  exercise,  vibration  of  the  cyst 
in  an  outward  direction  to  relieve  the  pressure  on  the  larynx, 
spinal  nerve  frictions ;  fronto-nasal  running  vibration ;  chest 
vibration,  stomach  exercise,  liver,  spleen  and  kidney  frictions. 
During  the  convalescent  stage  : — Chest  vibration,  stomach 
exercise,  kidney  frictions,  forwards  lying  back  exercise,  and  a  few 
general  strengthening  movements. 

Scarlet  Fever. 

During  the  spring  of  1902  there  occurred  a  small  epidemic  of 
scarlet  fever,  together  with  some  cases  of  mumps,  in  a  group  ot 
workmen's  houses  close  to  where  I  was  practising  at  Sanna. 

My  endeavours  to  isolate  the  patients  and  thus  stop  the 
progress  of  the  epidemic  were  not  always  successful ;  this  was 
due  to  a  lack  of  co-operation  on  the  part  of  the  patients  them- 
selves, who  did  not  and  apparently  could  not  understand  the  risk 
they  were  running  both  for  themselves  and  for  others.  The 
manager  of  the  estate  reported  that  he  frequently  saw  my  patients, 
while  yet  desquamating  and  hardly  free  from  fever,  walking  about 
out  of  doors.  Also,  in  order  to  save  themselves  and  their  relatives 
trouble,  some  of  the  patients  would,  as  soon  as  allowed  out  of 
bed,  when  they  wished  to  effect  a  rectal  evacuation,  walk  out  of 
doors  to  the  closets,  which  as  is  usual  in  Sweden  were  situated 
in  a  separate  building  removed  from  the  dwelling  houses  by  a 
distance  of  about  some  fifty  yards. 

The  following  was  the  routine  treatment  adapted  for  uncom- 
plicated cases  : — During  the  acute  stage  ;  head  exercise,  vibrations 
or  shakings  on  the  tonsils,  submaxillary  region,  and  on  any 
inflamed  lymphatic  glands  in  the  neighbourhood,  frictions  on 
the  nerves  of  these  parts ;  spinal  nerve  frictions,  heart  vibration 
ov  shaking,  side  shaking,  stomach  exercise,  kidney  frictions, 
spleen  frictions.  During  the  convalescent  stage;  forwards  lying 
back  exercise,  PP,  kidney  frictions,  stomach  exercise,  and  a  few 
purely  active  or  duplicate  movements  for  the  circulation,  and  to 
strengthen  the  entire  body. 

The  treatment  for  mumps  will  be  found  described  on  p.  290. 

The  same  method  of  testing  for  albumen  was  used  throughout ; 


266   ELEMENTS    OE  KELLGREN'S   MANUAL    TREATMENT 

nitric  acid  was  added  in  the  cold,  and  the  test  tube  allowed  to 
stand  for  fifteen  to  twenty  minutes  before  drawing  a  definite 
negative  conclusion. 

The  following  account  comprises  all  the  cases  of  the  scarlet 
fever  epidemic,  together  with  some  of  the  cases  of  mumps. 

Case  1. — Scarlatina  Anginosa. 

A.  C,  female,  aged  15. 

Previous  history. — Had  always  enjoyed  excellent  health. 
History  of  present  illness. — Patient  had  been  feeling  quite  well 
until  the  evening  of  February  20,  1902,  when  she  began  to  feel 


■^EB 

MARCH 

DATE 

21 

22 

23 

24  25 

26|27 

28 

1 

2 

3 

TIME 

M  E 

M  E 

M   E 

M  E 

M   E 

M  E 

M  E 

M  E 

M    E 

M   E 

M   E 

105° 
104° 
103° 
102° 

1  o  r 

100° 
99° 
98° 
97° 
96° 

A) 

<illa 

I 

h 

r 

\ 

^ 

/ 

A 

H 

M 

I 

J 

'\ 

, 

\, 

f 

A 

*  \ 

/ 

r 

> 

^ 

y 

Ia 

v 

/ 

y 

•^  \ 

/ 

PULSE 

-"f 

4>% 

^% 

^^^ 

96 

90 

82 
90 

100 
95 

96 
100 

94 

100 

72 

80 

70 
73 

BOWELS 

0 

1 

1 

2 

O 

1 

1 

1 

1 

1 

1 

ill  and  slept  badly.  At  5  a.m.  on  February  21  she  was  attacked 
with  bad  pain  in  the  head,  throat,  back,  and  abdomen,  and  also 
with  vomiting.  The  vomit  was  of  a  greenish  colour,  and  per- 
sisted at  intervals  for  about  seven  hours,  when  it  suddenly  ceased. 
Examination. — February  21,  1.30  p.m.  Patient  had  eaten 
nothing  during  the  day.      She  complained  of  bad   headache,  of 


SPECIFIC    INFECTIOUS    DISEASES  267 

pain  in  the  throat  and  back,  and  to  a  lesser  extent  of  pain  in  the 
abdomen.  The  tongue  was  white,  and  both  tonsils  were  swollen. 
The  abdominal  muscles  were  contracted,  and  there  was  general 
tenderness  of  the  abdomen,  especially  in  the  epigastrium.  A 
sample  of  the  vomit  that  was  shown  to  me  contained  large 
quantities  of  bile.  The  urine  was  highly  coloured,  scanty  in 
amount,  and  contained  no  albumen.  For  temperature  and  pulse 
see  separate  chart  (fig.  91).  Treatment  three  times  a  day  hence- 
forth. 

5  p.m.  Patient  had  vomited  once  since  last  treatment. 
Headache  worse ;  pains  in  both  legs  bad  set  in.  More  swelling 
of  tonsils,  which  were  redder  ;  white  patch  of  membrane  on  left 
tonsil,  none  on  right ;  cervical  glands  not  swollen.  A  bacterio- 
logical examination  of  a  portion  of  the  membrane  cultivated  in 
gelatine  for  twenty-four  hours  at  a  temperature  of  75°  F.  revealed 
a  number  of  whitish  spots,  which  under  the  microscope  were 
identified  as  cocci,  some  being  arranged  in  pairs  and  encapsuled, 
others  being  in  irregular  groups. 

8  p.m.  No  more  vomiting  had  taken  place.  Scarlatinal  rash 
commencing  on  face,  chest,  and  abdomen.  Skin  harsh  and  dry. 
Headache  worse  ;  pains  in  back  and  limbs  less  severe.  Membrane 
on  left  tonsil  larger.  No  albumen,  but  nitrate  of  urea  formed  on 
adding  nitric  acid. 

February  22. — Morning.  Patient  had  slept  very  little.  Very 
little  pain  in  back  and  legs.  Headache  better.  Face  very  red, 
except  just  around  mouth.  Eash  on  trunk  fully  developed. 
Membrane  on  both  tonsils.     Strawberry  tongue.     No  albumen. 

Afternoon.  No  pains  in  back.  More  pain  while  swallowing, 
but  membrane  about  the  same.  Enlarged  cervical  glands.  Rash 
on  arms,  but  not  on  legs.     No  albumen. 

Evening.  Headache  almost  gone.  Large  erytbematous-like 
patches  on  forearms ;  rash  on  legs,  but  not  yet  on  feet.  Tonsils 
about  the  same.  No  albumen  from  urine,  but  nitrate  of  urea 
formed  on  adding  nitric  acid. 

February  23. — Morning.  Rash  on  feet  visible  ;  face  less  red  ; 
desquamation  commencing  on  it.  Tonsils  about  the  same.  No 
headache. 

Afternoon.  Patient  had  eaten  again  after  two  days'  fasting. 
Throat  much  better ;  much  less  difficulty  in  swallowing,  and 
membranes   smaller  in   size.       Urine   clearer ;    no   albumen,   but 


268     ELEMENTS  OF   KELLGREN'S    MANUAL    TREATMENT 

iiitnile    of  urea    formed    on    adding    nitric    acid    to    all    samples 
collected  during  the  day.     Desquamation  over  entire  face. 

Evening.  Throat  better.  Patient  had  consumed  a  good  deal 
of  milk. 

February  24. — Morning.  Patient  had  slept  fairly  well.  No 
desquamation  on  body  as  yet.  Urine  :  no  albumen,  but  nitrate  of 
urea  formed  on  adding  nitric  acid. 

Evening.  Patient  had  been  sitting  up  during  most  of  the  day. 
Only  a  slight  difficulty  in  swallowing.  Urine  :  no  albumen  ;  from 
to-day  onwards  no  nitrate  of  urea  formed  on  adding  nitric  acid. 

February  25. — Morning.  No  difficulty  in  swallowing.  Mem- 
brane on  tonsils  gone,  and  the  latter  only  slightly  red.  Desquama- 
tion on  neck,  not  on  body.  Temperature  normal.  Treatment 
twice  a  day  henceforth. 

Evening.  Patient  said  she  felt  very  well,  although  weak. 
Up  during  most  of  the  day.     No  albumen. 

February  26. — In  consequence  of  her  mother  being  to-day 
attacked  with  scarlet  fever,  patient  was  up  all  day  and  attended 
to  cookmg  and  housekeeping,  in  the  absence  of  anybody  else  to  do 
the  work. 

Morning.  Face  hardly  red  at  all.  Desquamation  on  hands 
and  chest.  Patient  stronger  than  yesterday.  No  albumen. 
Treatment  once  a  day  henceforth. 

February  27. — Desquamation  over  whole  body,  but  not  yet  on 
hands.  Patient  stronger,  and  went  out  during  the  day  agamst 
my  orders.     No  albumen. 

February  28. — Patient  stronger.     No  albumen. 

March  1. — Desquamation  on  hands,  but  not  yet  on  feet,  which 
in  fact  never  peeled  at  all.     No  albumen. 

March  2. — Patient  felt  almost  restored.     No  albumen. 

March  3. — Patient  felt  quite  well ;  had  been  out  during  the 
greater  part  of  the  day  since  February  28  against  my  orders. 
Desquamation  onl}'  on  left  hand  ;  rest  of  body  normal.  No 
albumen.     Treatment  interrupted  for  three  days. 

March  6. — Desquamation  finished.  Patient  quite  strong. 
No  albumen.     Treatment  for  the  last  time. 

The  heart  remained  unaffected  throughout. 

October  8,  1902. — Patient  had  continued  in  perfect  health 
ever  since  her  illness,  and  stated  that  she  felt  better  than  previous 
to  it. 


SPECIFIC    INFECTIOUS    DISEASES 


269 


Case  2. — Scaklatina  Anginosa. 

Mrs.  H.  C,  aged  39,  mother  of  A.  C.  (Case  1,  p.  26(3). 

Previous  history. — Quite  good. 

History  of  present  illness. — Duriirg  the  evening  of  February 
2-5,  1902,  patient,  after  feeling  tired  all  day,  was  attacked  by  a  bad 
headache.  During  the  night  she  slept  badly,  and  during  the  next 
morning  had  fever,  sore  throat  and  pains  in  the  whole  of  the 
body,  the  headache  being  much  worse ;  she  suffered  from  rigors 
all  the  morning,  but  not  from  vomiting. 


FEB. 

vlARCH 

DATE 

26 

27- 

28 

1 

2     3  1 

TIME 

MAE 

MAE 

MAE 

M   E 

M   E 

M  E 

105° 
104° 
103° 
102° 
101° 
100° 
99° 
98  ° 
97  ° 
96  ° 

Axifla 

A 

n 

\ 

1 

\ 

1-1 

^ 

/ 

1 

/ 

'' 

4—^ 

/ 

PULSE 

^1? 

..^ 

% 

60 
62 

63     \7Z 
601 

Examination. — February  26,  12  noon.  There  was  redness  of 
the  throat,  and  a  large  patch  of  membrane  on  the  left  tonsil ;  the 
cervical  glands  were  enlarged.  A  bacteriological  examination  of 
the  membrane  revealed  the  same  features  as  in  the  case  of  her 
daughter  (p.  267) .  For  temperature  and  pulse,  see  separate  chart 
(fig.  92).     Treatment  three  times  a  day  henceforth. 

6p.m.  Headache  worse  ;  pains  in  legs  worse.  No  vomiting. 
Rash  on  face  except  around  mouth.     No  urine  passed  as  yet 


270     ELEMENTS  OF  KELLGREN'S    MANUAL    TREATMENT 

9  p.iu.  Headache  and  pains  in  legs  better.  Hash  on  face, 
but  nowhere  on  trunk  or  hnibs.  Urine  passed  at  (i  p.m.  ;  no 
albumen. 

P'ebruary  27. — Morning.  Patient  somewhat  better.  ^leiu- 
brane  on  both  tonsils.     No  albumen. 

Afternoon.     Great  pain  in  lumbar  region.     No  albumen. 

Evening.  Face  not  so  red  ;  throat  better.  Patient  had  eaten 
an  orange.     Strawberry  tongue.     No  albumen. 

February  28. — Morning.  Patient  much  better.  Face  no 
longer  red.  Membrane  on  left  tonsil  gone.  Temperature  normal. 
No  albumen. 

Afternoon.  Patient  complained  only  of  weakness  and  of  a 
difficulty  in  swallowing.  Blight  desquamation  on  face.  No 
albumen. 

Evening.     Membrane  on  right  tonsil  smaller.     No  albumen. 

March  1. — Morning.  No  pains  in  back,  but  some  in  both 
sides  over  lower  ribs ;  however,  I  could  find  nothing  objective  in 
this  area.  Pain  removed  by  treatment.  Patient  felt  weak ; 
otherwise  complained  only  of  a  slight  difficulty  in  swallowing. 
Treatment  twice  a  day  henceforth. 

Evening.  Patient  had  been  sitting  up  all  day.  Slight  mem- 
brane on  right  tonsil.  Desquamation  on  face  finished.  No 
albumen. 

March  2. — Patient  very  well  and  up  all  day.  Eating  her 
usual  fare.  No  membrane  on  tonsil.  Throat  normal.  No 
albumen. 

March  3. — Patient  went  out  during  the  course  of  the  day 
(temperature  below  freezing  point).  No  albumen.  Treatment 
once  a  day  henceforth. 

March  6. — Patient  quite  strong.  No  albumen.  Treatment 
finished.     Patient  went  back  to  work  on  the  estate  as  usual. 

The  heart  remained  unaffected  throughout. 

October  8,  1902. — Patient  had  continued  in  excellent  health 
ever  since  her  illness. 

Case  3. — Scarlatina  Anginosa. 

E.  J-i.,  female,  aged  lof. 
Previous  history. — Quite  good. 

History  of  present  illness. — Patient  felt  quite  well  until  the 
evening  of  February  27,  1902.     She  slept  badly,  and  on  getting 


SPECIFIC    INFECTIOUS    DISEASES  271 

up  on  February  '28  experienced  headache,  pain  in  back  and  legs, 
and  difficult}'  in  swallowing,  but  did  not  vomit.  She  walked 
over  to  my  villa  at  9  a.m. 

Examination. — Patient  looked  feverish,  and  I  could  see  a 
membrane  on  the  left  tonsil.  I  told  her  to  go  home  at  once, 
which  she  did.  On  arrival  home  she  was  seized  with  a  rigor 
lasting  ten  minutes. 


FEB. 

MARCH 

DATE 

28 

1 

2 

3 

4 

3 

6 

7 

8 

9 

TIME 

M    A  ;E 

MAE 

MAE 

M   E 

M  E 

M   E 

M   E 

M   E 

M   E 

M   E 

F° 

106' 
105° 
104° 
103° 
102° 
1  01° 
100° 
99° 
98° 
97° 

>fl 

ixillz 

) 

/s 

I 

\ 

^ 

\ 

r 

\/\ 

/ 

N 

A 

J 

M 

n 

.A 

\l 

' 

I 

J 

V 

Y 

\l 

V 

\ 

PULSE 

112  !^I12 
'"^  no  105 

<$. 

% 

90 
82 

79 

72 

72 
63 

66 
63 

81 
63 

58 
56 

M 

BOWELS 

0       1  0 

1 

1 

1 

1 

1 

1 

1 

1      1 

For  temperature  and  pulse  see  separate  chart  (fig.  93).  I 
requested  patient's  mother  to  keep  all  the  urine  passed,  and 
during  each  visit  I  estimated  the  amount,  took  the  specific  gravity 
and  tested  for  albumen.  (See  p.  273  for  results  of  this  examina- 
tion.)    Treatment  three  times  a  day  henceforth. 

3  p.m.  Headache  very  bad,  but  better  after  treatment. 
Patient  perspiring  freely. 

9  p.m.  Patient  had  been  asleep  during  the  afternoon,  and 
drank  some  milk  on  waking  up.  Headache  better.  Membrane 
on  both  tonsils  ;  considerable  difficulty  in  swallowing. 


272     ELEMENTS  OF    KELLGREX'S    MANUAL    TREATMENT 

March  1. — 9  a.iu.  Patient  had  slept  fairly  well.  Scarlatinal 
rash  on  body  and  face,  except  just  around  mouth.  Less  diffi- 
culty in  swallowing;  membrane  on  left  tonsil  smaller.  White 
tongue.     Pain  in  right  ear  ;  removed  by  treatment,  not  to  return. 

3  p.m.  Patient  had  been  sitting  up.  Eash  on  arms  ;  that  on 
body  less  red.     Strawberry  tongue. 

9  p.m.  Patient  feeling  very  well  in  spite  of  the  amount  of 
fever  present.  Enlarged  lymphatic  glands  on  right  side  below 
angle  of  jaw. 

March  2. — Morning.  Patient  had  slept  very  well.  Motion 
to-day  for  first  time  since  commencement  of  illness.  Rash  well 
marked  on  arms,  hairds  and  feet ;  desquamation  commenced  on 
face.  Membrane  on  left  tonsil  almost  gone,  and  that  on  right 
tonsil  much  smaller. 

Evening.  Condition  about  the  same.  Treatment  twice  a 
day  henceforth. 

March  3. — Desquamation  on  hands.  No  membrane  on  tonsils. 
Patient  better,  and  up  during  part  of  the  day. 

March  4. — Bash  almost  disappeared.  Desquamation  on  face 
nearly  finished  ;  hands  and  feet  never  peeled  at  all.  Difficulty  in 
swallowing  almost  gone.  Patient  up  all  day.  Headache  bad 
during  the  afternoon. 

March  5.— During  the  morning  bad  headache  and  pains  in 
stomach  and  side  ;  nothing  objective,  however,  in  the  areas  where 
they  were  felt.  Desquamation  almost  finished.  Patient  resumed 
usual  diet,  and  was  up  all  day. 

March  6. — Ko  headache  ;  throat  normal ;  pain  in  back  and 
sides,  but  not  so  bad  as  during  the  previous  day.  Nothing 
objective  in  sides. 

March  7. — Pain  in  one  side ;  patient  otherwise  normal, 
except  for  slight  weakness  and  the  last  remains  of  desquamation. 

March  8. — Desquamation  finished. 

March  9. — Patient  went  out  (temperature  —  7'C.),  and  was 
in  normal  health.     Treatment  finished. 

March  10. — Patient  out  all  day. 

The  heart  remained  unaffected  throughout. 

The  treatment  was  on  the  lines  already  indicated,  with  the 
addition  of  vibrations,  shakings,  and  nerve  frictions  over  the  pain- 
ful areas  in  the  back  and  sides,  and  on  one  occasion  (March  1) 
ear  exercise,  PP. 


SPECIFIC    INFECTIOUS    DISEASES  273 


Unne. 

Date                                                 in^Cub?'  Total                        Speoiflc 

Cent.  Gravity 

Feb.    -28      ..        Evening      ...       136  136        ...            1033 

'  Morning       ...       150     |  (  1034 

March  1     ...    \  Afternoon    ...       180  530         ...          I  1030 

Evening       ...       200     )  (  1030 

■  Morning      ...      260     |  I  1031 

Afternoon    ...       130      ,1-  .540+       ..          \  1029 


(  Evening       ...       150+)  (  1029 

I  Morning       ...       310     I  ^-qn  ,  '  1025 

t  Evening       ...       320+)"  ^^"+     ■■■  ]  1022 


(Morning  ...  220+)  „,„,  (1026 

]  Evening  ...  520      f  '*"+  ■■■          \  1018 

(  Morning  ...  520     )           .„„  (  1020 

(Evening  ...  170+ f  '^"  ■  -■         11019 


Morning      ...       560     1  „„„  f  1017 

Evening      ...       430+ 1  ^"+     •••  11015 


f  Morning  ...  750     [  „„„  (  1016 

I  Evening  ...  200+)  ^^~^  ■■           (1016 

(  Morning  ...  390     )  „,-  f  1017 

I  Evening  ...  .525+ f  '^     +  ••          (1018 

Morning  ...  360  ...  ..             1017 


About  six  weeks  later  patient  took  a  situation  as  a  general 
servant ;  the  last  news  I  had  of  her  (September,  1902)  reported 
her  to  be  in  very  good  health  indeed. 

Case  4. — Scarlatina  Simplex. 

G.  C,  female,  aged  U,  who  was  under  treatment  for  apoplexia 
cerebri,  and  was  living  in  one  of  the  houses  in  the  group 
previously  specified,  was  the  next  to  be  affected.  The  attack, 
which  was  a  very  mild  one,  began  on  March  1.  Patient  com- 
plained of  headache,  pain  in  the  back,  and  difficulty  in  swallowing. 
Beyond  very  slight  fever  (maximum  99'6°  in  the  axilla),  redness 
of  the  tonsils,  and  slight  redness  of  the  chest,  the  latter  dis- 
appearing the  following  day,  there  were  no  objective  symptoms. 
The  urine  remained  practically  normal,  the  highest  specific 
gravity  reached  being  1025,  and  I  never  found  any  albumen.  No 
desquamation  took  place.  The  treatment  was  administered  twice 
a  day  during  seven  days,  after  which  patient  came  to  me  again 
every  day  to  resume  the  previous  treatment  for  her  nervous 
condition.     (The  latter  will  be  found  reported  on  pp.  407-414.) 

The  heart  remained  unaffected  throughout. 
18 


274     ELEMENTS   OF   KELLOREN'S  MANUAL    TREATMENT 


Case  5. — Scarlatina  Anginosa. 

Mrs.  E.  K.,  aged  28. 

Previous  history. — Patient  had  al\va3s  been  anaemic  since 
about  the  age  of  twelve,  especially  from  about  her  fourteenth  to 
her  twenty-second  year. 

History  of  present  illness. — Patient  was  attacked  with  scarlet 
fever  simultaneouslj^  with  one  of  her  daughters  on  March  -5,  1902. 


MARCH 


DATE 

5     6 

7   1  8      9    1  10  1  II 

TIME 

AE 

MAE 

MAEiM  EM   EM  EM  E 

105° 
104° 
103* 
102° 
1  OI° 
100° 
99° 
98° 
97° 
96  ° 

Axi 

Ha 

■ 

\ 

11 

1 

■ 

^ 

, 

A 

ft 

\ 

,    1 

\ 

f\ 

^ 

,       "^1 

V 

V 

Sj 

r 

1 

PULSE 

96 
90 

"•^flf 

96 

78 

78 

76 

80     IsS 

84     83 

All  the  morning  of  that  day  she  had  rigors,  great  frontal  head- 
ache, and  pains  in  throat  and  back.  She  felt  inclined  to  vomit, 
but  did  not  actually  do  so. 

Examination. — Fever  (for  fever  and  pulse  see  separate  chart, 
fig.  94)  ;  redness  of  tonsils  and  fauces.  No  albumen  in  the  urine. 
Treatment  three  times  a  day  henceforth. 

Evening.     Membrane  on  right  tonsil.     No  albumen. 

March  6. — Morning.    Patient  had  slept  badly.    Pain  in  throat 


SPECIFIC    INFECTIOUS    DISEASES  275 

worse,  but  headache  better.  Scarlatinal  rash  on  face,  excepting 
around  mouth,  but  none  on  body.  Strawberry  tongue.  Mem- 
brane on  both  tonsils. 

Evening.  Face  had  typical  scarlatinal  look ;  general  con- 
dition about  the  same.     No  albumen. 

March  7. — Morning.  General  condition  improved.  Throat 
better  ;  face  not  so  red. 

Evening.  Patient  much  better ;  had  been  up  during  the 
afternoon  washing  dishes.  Membranes  on  tonsils  disappeared  ; 
only  some  redness  left.     No  albumen. 

March  8. — Treatment  twice  a  day  henceforth.  Morning. 
Patient  complained  of  headache  (menstruation  commenced  to- 
day), but  was  up  all  day  attending  to  household  duties.  Desqua- 
mation on  face  commenced.     No  albumen. 

March  9. — Excepting  for  slight  difticulty  in  swallowing  and 
weakness  patient  felt  normal.     No  albumen. 

March  10. — Patient  was  up  all  day,  and  baked  bread  ;  while 
so  doing  she  exposed  herself,  together  with  her  two  children 
(see  cases  6  and  7),  to  a  strong  draught  for  about  three  hours 
during  the  course  of  the  afternoon,  the  temperature  being  con- 
siderably below  freezing  point.  Stiffness  and  pain  in  the  muscles 
of  the  back  and  neck,  resulted  with  tenderness  to  pressure  in  the 
cervical  region  as  well  as  below  the  angle  of  the  jaw,  also  swelling 
of  both  parotids.  Treated  specially  for  this  with  muscle  knead- 
ing, muscle  frictions,  and  frictions  on  the  nerves  supplying  the 
muscles,  duplicate  movements  involving  them ;  vibrations  and 
frictions  on  the  parotid  glands.     No  albumen. 

Mr.i'ch  11. — Pain  in  neck  about  the  same,  but  less  stiffness 
in  the  muscles. 

March  12. — Muscles  normal ;  no  swelling  of  parotid.  Desqua- 
mation on  face  finished.     Treatment  finished. 

The  heart  remained  unaffected  throughout. 

On  April  18,  1902,  patient  returned  to  treatment,  in  con- 
sequence of  menstrual  disorders,  from  which  she  had  been 
suffering,  unknown  to  me,  for  the  past  fifteen  months.  The  flow 
came  on  irregularly  at  intervals  of  two  to  four  weeks,  and 
lasted  from  three  to  nine  days  on  each  occasion.  Patient  was 
given  the  manual  treatment  until  May  10,  when  menstruation 
was  once  more  normal.  She  was  still  in  very  good  health  when 
I  left  Sweden  in  October  of  the  same  year. 


276     ELEMENTS  OF  KELLGREN'S    MANUAL    TREATMENT 

Case  6. — Scarlatina  Gravior  with  Middle  Ear  Disease. 

M.  K.,  aged  G  months,  daughter  of  Mrs.  E.  K.  (see  Case  5),  was 
attacked  simultaneously  with  her  mother,  i.e.,  on  March  5,  1902. 

Previous  Jiistorij.  -Fsitient  was  born  at  full  time,  and  had 
always  heen  healthy. 

History  of  present  illness.-The  rash  came  out  on  March  (i, 
the  temperature  reaching  10'2°  (per  rectum) ;  there  were  no  throat 
symptoms  beyond  slight  redness  of  tonsils.  On  March  9,  desqua- 
mation had  commenced ;  the  temperature  was  normal.  On 
March  10  patient  was  exposed  to  a  draught  for  three  hours  as 
mentioned  on  p.  275,  in  consequence  of  which  acute  suppurative 
middle  ear  disease  set  in  on  the  left  side.  On  March  13  the 
abscess  perforated  the  tympanum,  and  the  discharge  continued 
to  be  yellowish  in  appearance  until  about  March  30,  whereupon 
it  became  watery,  and,  gradually  diminishing,  ceased  on  April  10. 
The  treatment  for  the  ear  condition  was  ear  and  mastoid 
vibration  and  syringing. 

I  was  only  able  to  test  the  urine  on  March  6,  12,  18,  and  14. 
It  contained  no  albumen  on  any  of  these  occasions. 

October,  1902. — Child  apparently  in  perfect  health.  Hearing 
normal.     No  ear  symptoms. 

Case  7. — Scarlatina  Anginosa,  followed  by  a   Chill  with 
Spinal  Symptoms,  and  Epidemic  Parotitis.  (?) 

E.  K.,  aged  2i  daughter  of  Mrs.  E.  K.  (Case  5,  p.  274.) 

Previous  history. — Quite  good. 

History  of  present  illness. — During  the  course  of  March  (3, 
1902,  mother  noticed  that  the  child  was  irritable,  always  wanting 
to  lie  down,  and  that  during  the  afternoon  her  face  was  very  red. 
I  was  sent  for  in  the  course  of  the  evening. 

Examination. — I  found  patient  with  a  scarlatinal  rash  on  trunk 
and  face,  except  just  around  the  mouth  ;  some  membrane  was 
present  on  both  tonsils.  There  was  fever  (for  fever  and  pulse  see 
separate  chart,  fig.  95).     The  urine  contained  no  albumen. 

March  7. — Rash  on  arms  and  legs.  Membrane  on  tonsils 
about  the  same.  Patient  consumed  some  bread  and  milk  during 
the  course  of  the  day,  and  got  up  and  walked  about  during  the 
afternoon.     No  albumen,  but  one  sample  of  urine  gave  a  pre- 


SPECIFIC    INFECTIOUS    DISEASES 


277 


cipitate  of  nitrate  oE  urea  on  adding  nitric  acid.  Treatment  three 
times  during  the  day. 

March  8. — Treatment  twice  a  day  henceforth.  Rash  less  red. 
Membranes  on  tonsils  less;  strawberry  tongue.  No  albumen  or 
nitrate  of  urea.     Patient  up  during  most  of  the  day. 

March  9.  —  Desquamation  commenced.  Appetite  returned. 
Ordinary  diet.     Patient  up  all  day.     No  albumen. 

March  10. — Condition  about  the  same  as  during  the  previous 
day.  Patient  exposed  to  a  draught  for  three  hours,  as  mentioned 
on  p.  275.     No  albumen. 

MARCH 


DATE 

6  ,  7   1  8  j  9  i  10 

II     12  [  13  '  14- 

13 

16 

17 

18 

19  j20 

TIME 

M   E 

MAE'M   E 

M   EM   E 

M  e!m  e 

M   E'M    E 

M   E 

M   E 

M   E 

M  E 

M  EW  E 

106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 
98° 
97° 

R 

;cti 

m 

\ 

hv 

k 

\A 

A 

\ 

\ 

/ 

u 

^, 

\ 

./ 

/ 

s 

A 

/ 

t^ 

/ 

y\ 

A 

. 

•^ 

/ 

■/ 

i/ 

PULSE 

leo 

^^^^'^40 

131 
140 

120 
136 

130 

140 

136 

140 

130 

159 

IS6 

154 

152 
130 

46 
153 

130 
140 

20 

129 

March  11. — Desquamation  finished,  tonsils  normal.  Eise  of 
temperature.  Patient  ate  nothing  during  the  whole  day.  No 
albumen . 

March  12. — Patient  better.  Fever  less.  During  the  after- 
noon, in  the  absence  of  her  mother,  patient  ran  out  in  the  open 
air  without  either  shoes  or  stockings  on,  the  temperature  being 
considerably  below  freezing  point. 

During  the  evening  she  was  worse,  and  suffered  from  great 
irritability,  retraction  of  head  and  photophobia.     No  albumen. 


27S     ELEMENTS  OF   KELLGREN'S   MANUAL   TREATMENT 

March  13. — Temperature  still  higher.  Retraction  of  head 
more  marked,  slight  stiffness  of  muscles  of  both  lower  limbs. 
Exaggerated  patellar  reflexes  and  slight  ankle  clonus  on  both 
sides.  Extreme  tenderness  over  dorsal  spinal  nerves,  and  some 
tenderness  over  most  areas  of  the  bodj'.  Incontinence  of  urine. 
I  could  not  test  for  albumen. 

March  14. — Condition  about  the  same.  I  could  not  test  for 
albumen. 

March  1.5. — Patient  better ;  temperature  lower.  No  retrac- 
tion of  head ;  no  stiffness  of  nniscles.  Reflexes  normal.  No 
tenderness  over  dorsal  spinal  nerves  or  rest  of  body.  No  incon- 
tinence of  urine.     No  albumen. 

During  the  evening  bilateral  swelling  of  parotids  and  sub- 
maxillary glands  (epidemic  parotitis?) 

March  16. — Swelling  of  salivary  glands  worse. 

March  17. — Swelling  about  the  same. 

March  20.— Swelling  better. 

March  24. — Swelling  almost  disappeared.  No  albumen  during 
the  last  nine  days. 

April  3. — Patient  normal ;  swelling  quite  disappeared.  No 
albumen  during  the  last  ten  days.     Treatment  finished. 

The  heart  remained  unaffected  throughout. 

October,  1902.^ — Patient  had  continued  in  excellent  health 
ever  since  her  illness. 

Treatment. 

The  ordinary  treatment  for  scarlet  fever ;  from  March  12  until 
16,  vibrations  over  dorsal  nerves  and  spinal  cord  for  about  ten 
minutes,  and  shaking  over  the  bladder  were  added.  March  1.5 
to  24,  ordinary  treatment  for  mumps.  March  25  to  April  3, 
ordinary  treatment  for  convalescence  from  fever. 

Case  8. — Mild  Case  of  Scarlatina  Anginosa. 

T.  J.,  male,  aged  16  ;  occupation,  stoker  in  a  factory. 

Previous  historij. — Quite  good. 

History  of  present  illness. — On  waking  up  at  about  the  usual 
hour  on  March  7,  1902,  patient  felt  ill,  had  a  headache  and  pain 
in  the  back,  and  his  mother  noticed  that  his  face  was  red.  I  saw 
patient  at  11  a.m.  of  the  same  day. 


SPECIFIC    INFECTIOUS    DISEASES  279 

Examination. — Scarlatinal  rash  011  face,  except  around  mouth, 
and  on  body.  Membrane  on  both  tonsils.  Fever  (for  fever  and 
pulse  see  separate  chart,  fig.  96).  No  albumen.  Treatment  twice 
a  day  henceforth. 

Evening.  Headache  worse ;  pain  in  throat  had  set  in.  No 
pain  in  back.  Lymphatic  glands  of  neck  swollen.  Rash  as 
before.     No  albumen.     After  treatment  no  headache. 

March  8. — Morning.     Face  less  red.     No  headache,  no  pain  in 
throat.     Patient  better,  and  got  up  during  the  course  of  the  day. 


DATE 

7 

8      9 

10 

II 

12 

13 

TIME 

M  E 

M   E 

M  E 

t  E 

M 

M 

H 

lOS" 

103' 
102' 
lOl" 
100' 
99* 
98" 
97' 
96  ■ 

Axi 

la 

\^ 

^. 

> 

fi 

\^ 

^ 

- 

PULSE 

10 

100 

lot 

Ob 

aa 

84. 

ec 

rz 

Evening.  Membrane  only  on  right  tonsil.  Patient  felt  nearly 
well.     No  albumen. 

March  9. — Membrane  on  right  tonsil  almost  gone.  Patient 
up  all  day.     Temperature  normal.     No  albumen. 

March  10. — Morning.  Patient  eating  as  usual  (meat  included). 
Desquamation  on  hands  and  face.  Patient  went  out  during  the 
afternoon  (against  orders). 

Evening.  No  membrane  on  tonsils,  but  lymphatic  glands  of 
neck  still  somewhat  enlarged.     No  albumen. 

March  11. — Patient  practically  normal.  No  albumen.  Treat- 
ment once  a  day  henceforth. 

March  12. — Desquamation  finished.  Patient  went  out  of 
doors  during  the  afternoon  for  three  hours  (temperature  a  good 
deal  below  freezing  point).     No  albumen. 


28o     ELEMENTS  OF   KELLGREN'S    MANUAL    TREATMENT 

March  13. — Patient  normal.     Out  all  day. 

March  14. — Treatment  for  the  last  time.  Patient  resumed 
work  as  stoker. 

The  heart  remained  unaffected  throughout. 

Patient  had  a  motion  every  day  of  his  illness. 

October  8,  1902. — Patient  had  continued  in  excellent  health 
ever  since  his  illness. 

Case  9. — Scarlatina  Anginosa. 

E.  W.,  male,  aged  23. 

Previous  history. — Quite  good. 

History  of  present  illness. — During  the  evening  of  March  16, 
1902,  he  began  to  feel  ill,  and  was  feverish.  During  March  17  he 
felt  pains  in  the  head,  throat,  back,  and  abdomen,  and  vomited 
fairly  continuously  from  9  a.m.  until  6  p.m.  I  first  saw  patient 
in  the  evening. 

Examination.— Face  very  red,  except  around  mouth  ;  scar- 
latinal rash  on  body  ;  membrane  on  both  tonsils.  Fever  (for 
fever  and  pulse  see  separate  chart,  fig.  97).     Urine  (see  p.  281). 


MARCH 


DATE 

17 

18 

19 

20 

21 

22 

23 

TIME 

E 

M  E 

M  E 

M  E 

M 

M. 

M 

F° 

106° 
105° 
104° 
103° 
102° 
lOT 
100° 
99° 
98° 
97° 

MOL 

ith 

^ 

r^ 

s 

^ 

L 

v» 

*^ 

PULSE 

100 

96 
88 

a* 

S2 

69 
80 

72 

68 

65 

SPECIFIC    INFECTIOUS    DISEASES  281 

March  18. — Treatment  twice  a  day  henceforth. 

Moi'ning.  Rash  on  hands  and  feet.  Membrane  on  tonsils 
about  the  same.  Headache  better  ;  pain  in  back  better  ;  no  pain 
in  abdomen. 

Evening.  Membranes  on  tonsils  gone,  only  redness  left. 
Strawberry  tongue. 

March  19. — No  pain  in  bead  or  anywhere  else.  Swallowing 
normal.  Desquamation  commenced  on  face.  Patient  ate  two 
eggs  and  meat  for  dinner;  until  then  had  only  taken  milk. 
Patient  got  up  during  the  course  of  the  day. 

Evening.     Desquamation  on  hands. 

March  20. — Patient  feeling  very  well.  Up  all  day  ;  no  fever. 
Desquamation  on  body.  Ordinary  diet,  although  appetite  not  yet 
quite  good. 

Evening.  Slight  pain  in  lower  part  of  back.  Tonsils  no 
longer  red.     Desquamation  on  feet. 

March  21. — Patient  up  all  day.  No  pain  in  back.  Desquama- 
tion on  body  finished.     Treatment  once  a  day  henceforth. 

March  22. — Desquamation  on  hands  finished  ;  only  the  ears 
left  peeling. 

March  23. — Patient  very  well  indeed. 

March  27. — Desquamation  only  on  ears.  No  albumen  during 
the  past  four  days.     Treatment  finished. 

March  30. — Desquamation  only  on  right  ear. 

April  1. — Desquamation  finished. 

Urine. 

Owing  to  his  misunderstanding  my  directions  the  patient  did 
not  invariably  keep  all  the  urine  passed,  but  sometimes  threw 
some  of  it  away. 


Date 

March  18 

„  19 

„  20 

„  21 

„  22 

,,  23 


'  Morning 
1  Evening 
j  Morning 
\  Evening 
(  Morning 
(  Evening 


uantity 
ill  cc. 

Specific 
Gravity 

220+        . 
150  + 

1040 

1085 

250  + 
155  + 

1033 
1028 

300+        . 
120+        . 

1030 
10-28 

250+        . 

1022 

450  + 

1021 

300  + 

1025 

Albumen 
none 


282     ELEMENTS  OE   KELLGREN'S    MANUAL    TREATMENT 

The  heart  remained  unaffected  throughout. 

Patient  remained  in  veiy  good  health  until  about  the  middle 
of  June,  1902,  when  he  emigrated  to  America ;  since  then  I  have 
heard  nothing  of  him. 


Case  10. — Scarlatina  Anginosa  followed  by  Epidemic 
Parotitis. 

S.  N.,  female,  aged  7. 

Previous  history. — Patient  had  never  been  very  strong. 

History  of  present  illness. — Patient  complained  of  headache 
and  sore  throat  during  the  morning  of  March  18.  She  slept  very 
badly,  and  during  the  morning  of  March  19  complained  of  pain 
in  the  throat,  head,  legs  and  back.  She  felt  a  desire  to  vomit, 
but  did  not  actually  do  so.  Three  diarrhoeic  motions  took  place 
during  the  course  of  the  morning.  Her  mother  noticed  that  the 
patient's  face  and  body  were  red.  I  first  saw  patient  at  3  p.m. 
on  March  19. 

Examination. — Scarlatinal  rash  on  face  excepting  around 
mouth,  also  on  body,  but  none  on  hands  or  feet.  Some  fever 
(for  fever  and  pulse  see  separate  chart,  fig.  98).  Membrane  on 
both  tonsils.  Urine,  no  albumen  (see  p.  284).  Treatment  twice 
a  day  henceforth. 

Evening.  Patient  ate  sausages  and  brown  beans  for  dinner, 
and  took  milk  at  intervals  during  the  course  of  the  day,  also  some 
coffee  ;  had  two  more  diarrhoeic  motions.  Rash  on  hands.  Pain 
in  back  very  severe,  pain  in  throat  about  the  same  ;  both  much 
relieved  by  treatment.     Some  headache. 

March  20. — Patient  had  slept  very  well  during  the  night. 
Non-diarrhoeic  motion  during  the  morning.  No  headache,  only 
slight  pain  in  back  and  throat.  Desquamation  commenced  on 
body  and  face.  Patient  got  up  during  the  course  of  the  day,  and 
ate  her  usual  fare. 

March  21. — Morning.  No  pain  in  back  or  throat ;  some 
membrane  on  the  tonsils  still  present.     Patient  up  all  day. 

Evening.  Membrane  on  tonsils  almost  gone.  Eise  of  tem- 
perature, and  all  the  signs  of  mumps  on  both  sides  (one  brother 
had  the  latter  disease  about  three  weeks  ago  and  another  brother 
developed  it  yesterday). 


SPECIFIC    INFECTIOUS   DISEASES 


283 


March  22. — Membrane  on  tonsils  gone.  Mumps  fully 
developed.  Patient  complained  of  a  sense  of  pulsation  in  right 
ear.     Membrana  tympani  normal.     Patient  up  all  day. 

March  23. — Mumps  subsiding ;  no  difficulty  in  swallowing. 
No  pulsation  in  ear.  Desquamation  on  face  finished,  and  finish- 
ing on  body.  Hands  and  feet  never  desquamated.  Patient  up 
all  day. 

March  24. — Swelling  still  less,  only  slight  in  right  parotid, 
none  in  left.     Patient  felt  very  well. 


MARCH 


DATE 

19 

20 

21 

22 

23 

24 

25 

TIME 

A  E 

M   E 

M   E 

M   E 

M  E 

M   E 

^   E 

F° 

104° 

Axil 

la 

t 

\ 

A 

A 

100° 

\ 

\ 

/^ 

/I 

r 

99° 
98° 

U 



k^ 

\/ 

PULSE 

144 

120 
\3i 

120 

135 

lie    104 

I33|    IOC 

96 
98 

90 

100 

March  25. — Patient  felt  quite  well.  Treatment  only  once  a 
day  henceforth. 

March  2G. — Desquamation  finished.  Patient  out  all  day. 
No  albumen. 

March  27. —  Only  slight  swelling  in  right  parotid.    No  albumen. 

March  81.— Patient  normal.     Treatment  finished. 

The  heart  remained  unaffected  throughout. 


284  ELEMENTS  OF   KELLGREN'S    MANUAL    TREATMENT 


March  19 
„     20 


Eveniug 
f  Morning 
i  Evening 
J  Morning 
1  Evening 
j  Morning 
(Eveniug 

( Morning 
I  Evening 
(Morning 
{Evening 
I  Morning  I 
(Evening  | 


Urine. 


Quantity 

70 

'200+  I 
160      I 

2G0  I 
150+  I 
325  1 
350     / 

375  I 
100+  ) 
260  ) 
135+  1 

620 


Total 

70 

360+ 

410+ 
675 
475  + 
395  + 
620 


lirav.ty 
1020 
11018 
( 1018 

( 1023 
■(  1018 
(1016 
1 1017 
(1013 
(1014 

(1010 
'( 1012 

1016 


Albumen 
none 


Patient  remained  quite  well  until  April  "24,  1902,  when  she 
left  the  district :  I  have  not  heard  of  her  since. 


Case  11. — Scarlatina  Anginosa  with  Epidemic  Parotitis. 

A.  N.,  male,  aged  (5^  months,  brother  of  S.  N.  (Case  10). 

Previous  history. — Patient  was  a  full-time  child  and  had  never 
been  ill.     Was  stroilg  and  big  for  his  age. 

History  of  present  illness. — During  the  evening  of  March  28, 
1902,  patient  vomited,  and  during  the  night  slept  very  httle, 
vomiting  almost  every  half  hour.  The  mother  examined  him 
carefully  for  any  signs  of  a  rash,  but  found  none.  (1  had  told  her 
to  report  to  me  at  once  if  any  more  of  her  children  began  to  look 
red  in  the  face  or  have  a  rash  on  the  body.)  I  first  saw  patient 
on  the  morning  of  March  29  ;  nothing  objective  except  slight 
fever  (100").  During  the  afternoon,  however,  he  developed 
symptoms  of  scarlet  fever  and  mumps  simultaneously. 

Examination. — Scarlatinal  rash  on  face  except  around  mouth, 
also  on  body;  membrane  on  right  tonsil;  swelling  of  both  parotid 
and  submaxillary  glands,  the  swelling  passing  downwards  into 
the  neck.  For  temperature  see  separate  chart,  fig.  99.  Treat- 
ment twice  a  day  henceforth. 

March  30. — Morning.  During  the  previous  day  patient  ate 
nothing,  but  to-day  took  the  breast  as  usual.  Membrane  on 
tonsil  gone.     Strawberry  tongue.     Rash  on  arms  and  legs. 

Evening.     Better. 

March  31. —  Morning.     Patient   had    slept    very   well.     Des- 


SPECIFIC   INFECTIOUS    DISEASES 


285 


quamation  on  back.  Swelling  of  parotid  and  submaxillary  glands 
better. 

April  1. — Redness  on  body  diminisbing.  Swelling  of  salivary 
glands  less. 

April  2. — Redness  almost  disappeared.  Desquamation  on  back 
finished.  Rise  of  temperature,  but  I  could  find  nothing  objective 
to  account  for  this. 

April  8. — Desquamation  on  abdomen,  face  and  legs.  Hands 
never  desquamated  at  all.  Treatment  only  once  a  day  henceforth 
(during  the  evening). 


MARCH 

^PR 

L 

DATE 

29  30   31      12     3     4 

5  1  6 

7 

8 

9 

TIME 

M   E 

M   EiM   EiM   EM   EJ   E   i  E 

E   '  E 

E 

E 

E 

F° 

106' 
105° 
104.° 
103° 
102° 
1  0  1° 
100° 
99° 
98  ° 
97  ° 

Rectun 

1 

/ 

\ 

A 

/ 

\ 

K 

\ 

/ 

\ 

/ 

V 

V 

Sk. 

N 

V 

^*N 

^ 

April  4. — Desquamation  on  feet  commenced. 

April  5. — Swelling  of  parotids  much  less. 

April  6. — Desquamation  only  on  feet. 

April  14. — Desquamation  finished.  No  .swelling  of  parotid  or 
submaxillary  glands.     Patient  normal.     Treatment  finished. 

The  heart  remained  unaffected  throughout. 

I  was  only  able  to  test  the  urine  once,  on  the  fourth  day  of 
the  illness.     It  contained  no  albumen. 


286     ELEMENTS  OF    KELLGREN'S    MANUAL    TREATMENT 

Case  12. — Scarlatina  Simplex  followed  by  Epidemic 
Parotitis. 

I.  J.,  female,  aged  lii. 

Previous  history. — Patient  of  a  very  neurotic  temperament ; 
bad  fainted  on  occasions,  and  twice  during  the  year  had  had 
hysterical  attacks.     Had  always  been  rather  anaemic. 

History  of  present  illness. — Patient  was  attacked  during  the 
evening  of  April  4,  1902,  with  pains  in  the  head  and  back  ;  1  saw 
her  at  9  p.m.  of  the  same  day. 

Examination. — Temperature  101°  (for  temperature  and  pulse 
see  chart,  fig.  100),  otherwise  nothing  objective.  Throat  un- 
affected.    Urine  (see  pp.  287,  288). 


APRIL 

DATE 

4- 

5 

6 

7 

a 

9 

10 

TIME 

.  E 

MAE 

M  E 

M  E 

M  E 

.A- 

-A 

F° 

106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 
98° 
97° 

MOL 

jth 

1 

A 

A 

N 

JV 

\ 

\A 

V 

V 

\ 

\ 

-^ 

/' 

PULSE 

•  108 

<% 

104 
101 

rs 

84 

69 
70 

62 

92 

April  5. — Morning.  Patient  had  been  vomiting ;  she  had 
suffered  from  great  frontal  headache  and  pain  in  the  back,  but 
had  no  difficulty  in  swallowing.  Scarlatinal  rash  on  face,  except 
around  mouth,  also  on  body ;  not  yet  on  arms.  Redness  of 
both  tonsils. 


SPECIFIC    INFECTIOUS    DISEASES  287 

Evening.  Patient  had  eaten  nothing  during  the  day.  Pains 
in  head  and  back  better.     Rash  on  arms.     Treatment  three  times. 

April  6. — Morning.  Patient  felt  better.  No  pain  in  the  back  ; 
but  still  some  headache  present.  Strawberry  tongue.  Patient 
ate  pancake  for  breakfast. 

Evening.  Headache  better,  but  pains  in  knees.  Rash  on 
body  disappearing,  entirelj'  gone  from  both  arms.  Treatment 
twice  a  day  henceforth. 

April  7. — Rash  on  body  gone;  only  slight  redness  of  face, 
on  which  desquamation  had  set  in.  No  pains  anywhere.  Patient 
got  up,  and  remained  up  during  most  of  the  day ;  felt  weak  but 
otherwise  normal. 

Evening.     Desquamation  on  hands. 

April  8. — Patient  resumed  ordinary  diet,  including  meat, 
coffee,  &c.  During  the  evening  the  urine  formed  nitrate  of  urea 
on  adding  nitric  acid. 

April  9.  — Treatment  once  a  day  henceforth.  Patient  up  all 
day.     Desquamation  nearly  finished. 

April  10. — Desquamation  only  on  one  finger. 

April  11. — Desquamation  finished.  Patient  went  out  (against 
my  orders)  for  a  two-mile  walk  (temperature  considerably  below 
freezing  point). 

April  12. — Patient  was  out  for  three  hours  (against  my  orders). 

April  13. — Pains  in  both  knees  and  muscles  of  anterior  tibio- 
fibular regions  of  both  sides ;  removed  by  treatment  (vibrations, 
muscle  kneadings,  foot  rolling,  PP,  flexion,  AR,  extension,  PR, 
anterior  tibial  nerve  frictions,  PP). 

April  14. — An  attack  of  mumps  supervened,  the  temperature 
rising  to  100"4°  F.     Treatment  twice  a  day  henceforth. 

April   15. — Fever   gone.      Swelling   of    salivary    glands   less. 

April  19. — Hardly  any  signs  of  mumps  left.  Treatment  this 
morning  for  the  last  time. 

April  22. — No  sign  of  mumps  left. 

The  heart  remained  unafl:'ected  throughout. 

Urine. 


April  5 


( Morning 
jEveniDg 

Quantity 

100+1 
90+ f 

Total 
190+      ... 

Specific 
Gravity 

(1042 
)  1042 

j  ilorning 
(Evening 

200     ) 
250+  1 

450+      ... 

fl040 
1 103G 

288     ELEMENTS  OF   KELLG REN'S   MANUAL    TREATMENT 

Date  ^^"^'^ity  Total  |P^^,i.Jj  Albumen 

\nril      7  (Morning        ...         260      I  20+  ^'^^^^         -      '^°'^^ 

April      I     ...      |K^,3ni„g  160+)  ^''"+       -      "(1036 

(Moi-niDg        ...         250      I  „„  J1030         

■■•      1  livening        ...         240+ [  "'""'"      ■••       (1034         

„       9     ...  ...  ...         910  910  1031         ...  „ 

,,     10     ...  ...  ...         860+  860+      •■■        1028 

Patient,  excepting  for  catching  a  bad  cold  about  a  fortnight 
later,  remained  in  very  good  health  until  June  of  the  same  year ; 
in  that  month  she  took  a  situation  as  servant  and  I  heard  no 
more  of  her. 


Case  13. 

Ur.  Harry  Kellgren  has  kindly  allowed  me  to  publish  the 
following  case  treated  by  him,  January-February,  1901 : — 

H.  A.,  aged  7. 

Previous  history. — Patient  when  quite  young  had  measles,  but 
otherwise  had  always  been  strong  and  healthy.  Since  attending 
school,  patient  had  from  time  to  time  felt  very  tired  in  his  eyes 
and  occasionally  had  headaches  together  with  a  slight  amount  of 
fever  and  vomiting. 

History  of  present  illness. — In  consequence  of  patient  looking 
ill,  I  was  sent  for  during  the  evening  of  January  25,  1901. 

Examination. — Patient  complained  of  headache,  vomiting, 
some  cold  in  the  head,  and  pain  in  the  throat  on  swallowing. 
On  inspection  the  tonsils  were  red,  the  tongue  rather  furred ; 
the  eyelids  swollen,  and  could  only  be  opened  with  difficulty. 
Photophobia.  Skin  somewhat  raw.  No  fever;  pulse  full  and 
strong.      Lungs  and  heart  healthy. 

January  2G. — Morning.  The  symptoms  ah-eady  mentioned 
unchanged.  Light  red  eruption  on  the  trunk.  Temperature 
40'2°,  pulse  110.  Motion  during  the  morning.  Urine  very  scanty, 
and  concentrated,  but  not  otherwise  abnormal.  Treatment  three 
times  a  day. 

January  27. — Morning.  There  had  apparently  been  high 
fever  during  the  night.     Temperature  40"4°,  pulse  120. 

Noon.  Headache  and  sore  throat  much  better.  No  vomit- 
ing.    Strawberry  tongue. 

Evening.  Typical  scarlatinal  rash,  very  marlced  over  the 
whole   body,  excepting  on  the  forehead  and  around  the  mouth. 


SPECIFIC    INFECTIOUS   DISEASES  289 

Frequent  micturition  ;  urine  contained  urates.  Temperature  39'5', 
pulse  110. 

January  28. — Morning.  Patient  had  slept  well  ;  disposition 
much  more  cheerful  ;  appetite  returned.  Kash  a  little  paler. 
Temperature  37'6°,  pulse  90. 

Evening.  Temperature  37'5°,  pulse  100.  Desquamation  con- 
siderably advanced.  Eyelids  better.  Tonsils  normal ;  tongue  no 
longer  furred.     Appetite  good  ;  patient  cheerful. 

January  29. — Morning.  Temperature  37"3°,  pulse  84.  Patient's 
appetite  and  frame  of  mind  very  good.  The  kidneys,  which  had 
throughout  been  very  sensitive,  no  longer  so  tender.  Urine 
normal. 

January  30.— Temperature  37"2°,  pulse  74.  Motion  during 
the  day.  General  condition  very  good.  Desquamation  not  yet 
quite  completed.     Kidneys   still   rather   tender.     Urine   normal. 

The  treatment  up  to  date  had  been  :  head  exercise,  throat 
exercise,  spinal  nerve  frictions,  stomach  exercise,  kidney  frictions, 
shaking  and  vibration  over  the  bladder  ;  stretch  lying  running 
nerve  frictions,  PP. 

January  31. — From  to-day  onwards  tlie  patient  underwent 
a  general  strengthening  treatment. 

February  5. — The  treatment  was  administered  for  the  last 
time.  The  patient  was  then  quite  cured,  and  felt  stronger  and 
better  than  before  his  illness. 


Epidemic  Parotitis. 

The  following  was  the  worst  case  that  occurred  during  the 
epidemic  referred  to  on  p.  265  : — 

G.  J.,  male,  aged  9. 

Previous  histori/. — Patient  suffered  from  tuberculous  glands 
in  the  neck  for  a  year,  1898  to  1899,  but  recovered,  and  since 
then  had  always  been  fairly  strong. 

History  of  present  illness. — Patient  went  to  school  as  usual  on 
April  10,  1902 ;  during  the  evening  of  that  day  he  experienced 
a  slight  pain  in  his  neck.  He  passed  a  bad  night,  and  was  much 
worse  the  following  morning  (April  11)  ;  there  was  more  pain, 
and  swelling  had  arisen  on  both  sides  of  his  neck.  I  was  sent 
for  at  10  a.m. 
19 


290      ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

Examination. — Swelling  of  both  parotid  c,'laiids,  extending 
down  side  of  neck,  and  swelling  of  both  submaxillary  glands  ; 
thickness  of  speech,  difficulty  and  pain  on  talking;  pain  on 
swallowing.  Great  tenderness  over  the  swollen  glands.  Tem- 
perature 102°,  pulse  100.     Treatment  twice  a  day  henceforth. 

Evening.  Condition  about  the  same  ;  temperature  102",  pulse 
100.     Patient  had  eaten  nothing  during  the  day. 

April  12. — Morning.  Swelling  less.  Temperature  99"6°, 
pulse  84. 

Evening.  Swelling  less  ;  temperature  lOO'B"',  pulse  84.  Patient 
had  drunk  some  milk  and  eaten  some  rusks. 

April  18. — Morning.  Swelling  less ;  hardly  any  pain  at  all 
on  swallowing.  Temperature  98"6°,  pulse  82.  Appetite  had 
returned,  and  usual  food  w'as  taken.  Patient  got  up,  and,  against 
my  orders,  went  out  during  the  afternoon. 

Evening.  Swelling  still  less;  temperature  98' 1°,  pulse  90. 
Swallowing  normal. 

April  14. — Morning.  Temperature  98'4°,  pulse  84.  Patient 
out  all  day. 

Evening.  Temperature  98°,  pulse  76.  Swelling  still  less, 
and  confined  to  the  parotids.     Submaxillary  glands  normal. 

April  15. — Morning.     Temperature  99°,  pulse  78. 

Evening.     Temperature  98°,  pulse  72.     Swelling  still  less. 

April  16. — Morning.  On  my  arrival  I  found  that  patient  had 
felt  so  well  that  he  had  gone  to  school  as  usual. 

Evening.  Very  little  swelling  of  parotids  ;  temperature  98'4°, 
pulse  74.     Treatment  as  usual. 

April  17. — Hardly  any  swelling  of  parotids.  Treatment  once 
a  daj'  henceforth. 

April  20. — No  swelling.     Treatment  finished. 

The  temperatures  were  all  taken  in  the  mouth. 


Treatment. 

Vibrations  and  shakings,  followed  by  frictions  on  the  salivary 
glands  and  on  the  swollen  lymphatic  glands;  running  vibrations 
from  above  downwards  along  the  sterno-mastoids ;  frictions  on 
the  facial  nerves  and  on  the  nerves  lying  in  the  submaxillary 
region.     General  treatment  for  fever. 


SPECIFIC   INFECTIOUS   DISEASES  291 


Diphtheria. 

Nasal,  tonsillar,  pharyngeal,  and  laryngeal  diphtheria  occurring 
in  myself ;  treated  December,  1899,  to  January,  1900. 
Edgar  F.  Cyriax,  aged  2.5. 

Previous  history. — Patient  had  been  feeling  more  or  less 
weak  and  fatigued  for  several  months,  and  had  been  attending 
continually  to  a  child  with  diphtheria  from  November  27  to 
December  8,  1899 ;  this  had  caused  a  considerable  extra  strain 
(see  appendix). 

History  of  present  illness. — On  December  2  he  felt  some 
uneasiness  in  his  tonsils.  He  slept  badly  during  that  night,  and 
on  December  3  there  appeared  redness  and  swelling  of  both 
tonsils ;  during  the  evening  of  the  same  day  a  small  patch  of 
membrane  could  be  seen  on  the  left  tonsil. 

December  4. — Membrane  had  spread  to  right  tonsil,  and  was 
of  a  gray  colour.  Swallowing  was  difficult ;  tonsils  were  very 
much  swollen.  During  the  course  of  the  day  the  uvula  became 
enlarged,  and  the  voice  slightly  husky. 

December  .5. — ^During  the  night  a  further  increase  took  place 
in  the  size  of  the  uvula,  which  became  so  long  that  it  continually 
touched  the  patient's  tongue  and  fauces,  preventing  any  sleep  ; 
a  great  amount  of  salivation  was  set  up.  The  voice  became  more 
and  more  hoarse  during  the  course  of  the  day.  During  the 
evening  the  bacteriological  laboratory  reported  that  a  culture 
taken  from  patient's  throat  the  day  before  contained  diphtheria 
bacilli.  Some  thick  stringy  mucus  from  nose  had  been  continu- 
ally coming  away  during  the  day ;  sometimes  it  was  tinged  with 
blood.     For  temperature  and  pulse  see  separate  chart,  fig.  101. 

December  6. — Patient  delirious  during  the  night ;  slept  very 
little  indeed.  On  waking  voice  reduced  to  a  whisper.  Bloody 
mucus  from  nose  in  great  quantity. 

December  7. — Occasional  delirium  during  the  night ;  patient 
hardly  slept  at  all.  Symptoms  much  the  same  as  before, 
excepting  that  salivation  was  slightly  less,  and  swallowing  a  trifle 
easier. 

December  8. — Patient  slept  fairly  well.  Membrane  diminish- 
ing in  size,  salivation  much  less.  Bloody  mucus  from  nose  less 
in  amount. 

December   9. — Tonsils    smaller,    and  in    consequence   patient 


292      ELEMENTS  OF  KELLGUEN'S  MANUAL   TREATMENT 

was  enabled  to  see,  on  examining  with  a  looking-r^lass,  that  the 
pharynx  was  full  of  gray  membranes. 

Decemer  10. — Only  a  small  patch  on  right  tonsil.  Very  little 
bloody  mucus  coming  from  nose. 

December  11. — Patient  coughed  up  blood  clots  continually. 

December  12. — Patient  still  coughing  up  blood  clots. 

December  13. — Membranes  on  tonsils  and  in  pharynx  almost 
gone  ;  some  inflammation  still  visible.     Swallowing  quite  easy. 

December  14. — Some  inflammation  of  right  tonsil ;  left  tonsil 
normal.     Voice  no  better  (still  a  whisper). 


DEC. 


DATE 

5 

6 

7 

B 

9 

10 

1  1 

12 

13 

14 

15 

TIME 

E 

MAE 

MAE 

MAE 

MAE 

MAE 

MAE 

MAE 

M    E 

M   E 

M   E 

106° 
105° 
104° 
103° 
102° 

1 0  r 

100° 
99° 
98° 
97° 

Re 

ctu 

n 

\ 

ft 

A 

A 

A 

h 

f 

A 

\v 

V 

P 

i 

V* 

\, 

/ 

^ 

y 

w 

PULSE 

106 

% 

% 

'"•> 

% 

% 

% 

% 

76 
66 

70 

63 

66 

December  17. — Patient  went  out  for  a  short  walk  (temperature 
about  —  10°  C).     Tonsils  and  pharynx  normal  in  every  respect. 

December  18. — Patient  went  out  for  a  drive  of  one  hour. 

The  treatment  was  now  stopped  until  December  21,  owing  to 
unavoidable  circumstances.  Patient  was  treated  December  21, 
22,  28 ;  then  there  was  another  break,  and  after  that  the  treat- 
ment could  only  be  administered  about  every  other  day,  the  actual 
dates  being  December  28,  29,  January  1,  8,  6,  8,  10,  11,  12 ;  after 


SPECIFIC   INFECTIOUS    DISEASES  293 

the  latter  date  the  treatment  had  to  be  stopped  altogether. 
Already,  on  December  21,  the  voice  had  begun  to  come  back  ; 
after  January  12  it  continued  to  improve  by  itself.  By  February 
10  the  voice  was  normal,  and  patient  could  sing  as  usual. 
A  slight  attack  of  peripheral  neuritis  supervened,  causing 
no  inconvenience  beyond  a  feeling  of  pins  and  needles  in  the 
hands  and  feet.  After  lasting  three  weeks  or  so,  it  disappeared 
without  treatment. 

The  lungs  and  heart  remained  healthy  throughout. 


Treatment. 

At  first  shakings  and  vibrations  of  the  larynx,  pharynx,  and 
trachea,  &c. ;  frictions  over  the  nerves  in  these  parts,  chiefly  the 
superior  and  recurrent  laryngeal,  also  great  occipital  and  spinal 
nerves ;  general  treatment  for  fever.  Patient  did  not  remain  in 
bed  during  the  acute  stage ;  he  got  up  every  morning  and  spent 
most  of  the  day  sittuig  up  or  walking  about.  Diet  was  whatever 
patient  liked,  but  the  amount  of  food  taken  was  limited,  in  con- 
sequence of  the  severe  pain  induced  on  attempting  to  swallow. 
During  the  convalescent  stage,  the  treatment  was  specially 
directed  towards  stimulation  of  the  nerves  of  the  larynx,  and 
also  of  the  nervous  system  generally. 

No  serum  was  used,  the  patient  absolutely  declining  any. 

March,  1902. — Patient  had  been  very  well  ever  since.  In 
May,  1902,  however,  an  attack  of  rheumatic  fever  and  erythema 
set  in.     The  case  will  be  found  described  on  pp.  300  to  308. 


Erysipelas  Migrans  Bullosum. 

In  the  town  of  Huskvarna  several  cases  of  erysipelas  occurred 
during  the  summer  of  1900. 

The  case  described  was  one  of  three  occurring  in  the  same 
street. 

K.  O.,  female,  aged  5,  came  under  the  manual  treatment 
on  August  29,  1900. 

Previous  history. — Quite  good. 

History  of  present  illness. — Everything  was  apparently  normal 
until  the  morning  of  August  26,  when,   after   a  restless  night. 


294    ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

patient  said  that  she  felt  ill,  and  complained  of  pain  in  the  right 
inguinal  region  ;  she  also  experienced  several  shivering  attacks. 
Patient's  mother  noticed  nothing  unusual  except  that  the  child 
seemed  feverish,  and  that  there  was  a  small  scratch  on  the  front 
of  the  lower  leg  at  about  the  junction  of  its  middle  and  lower  third. 
During  the  afternoon  patient  got  up,  said  she  felt  quite  well 
again,  and  played  about  as  usual.  On  getting  up  on  August  27 
she  felt  fairly  well ;  but  after  a  little  she  experienced  further 
shivering  attacks  and  some  fever,  and  went  to  bed  again  at  about 
11  a.m.  The  parents  observed  that  around  the  scratch  noticed 
during  the  previous  day  there  was  a  bright  red  patch  about  the 


AUG. 

SEPT 

DATE 

29 

30 

31 

1 

2 

3 

4 

5 

6 

7 

8    t    9    [10 

II 

12 

I3|l4.| 

TIME 

E 

MAE 

MAE 

M   E 

M   E 

M   E 

M   E 

M   E 

M   E 

M   E 

M   E 

M   ElE 

E 

E 

E 

E 

106' 
lOS" 
I04° 
103* 
102" 
lOl" 
100" 

98  • 
97* 

Rect 

im 

^^ 

j  / 

> 

/ 

^H 

A 

\ 

'^\ 

i 

iA 

A 

h 

t 

)/^ 

A 

/  / 

/ 

/ 

J 

^ 

/ 

/ 

Y 

/ 

, 

y 

y 

V 

r 

PULSE 

32120  110  120:il6  13512^ 
32K2II0  120!%  120120 

90  120 
90  108 

lUlOS 
04  104 

78  106 

B5  110 

96  lie 

rr  122 

88  94 

96  90 

90  100 

14 

IB 

16 

OD 

00 

size  of  a  shilling.  On  August  28  the  general  condition  was 
worse,  while  the  red  patch  had  grown  to  about  three  inches  in 
length.  On  August  29  the  general  condition  was  still  worse  and 
the  red  patch  still  larger,  and  I  was  called  in. 

Examination. — August  29,  6  p.m.  Patient  in  bed,  looking 
very  worn  out  (she  had  hardly  had  any  sleep  for  two  nights), 
feverish  and  shivering.  Temperature  103'6°,  pulse  132.  (For 
temperature  and  pulse,  see  separate  chart,  fig.  102.)  Eight  lower 
leg  and  foot  swollen ;  a  large,  bright  red,  inflammatory  patch 
could  be  seen  extending  right  round  the  limb  from  about  the 
scaphoid  bone  to  about  two  inches  below  the  knee-joint.  On 
the  patch   many  buUffi  (some  about  an   inch    long)    filled  with 


SPECIFIC    INFECTIOUS   DISEASES  295 

yellowish  exudation  ;  in  some  places  they  communicated  with 
one  another.  In  between  the  bullae  the  red  area  was  tense, 
glazed-looking,  and  slightly  oedematous ;  the  uiargins  were  raised 
and  well  defined  Some  oedema  of  the  foot.  Great  feeling  of 
irritation  in  the  affected  area ;  not  much  pain  in  it,  but  great  ten- 
derness to  touch.  Several  enlarged  lymphatic  glands  about  the 
size  of  a  walnut  in  the  right  grom  ;  kidney  and  spleen  tender ; 
urine  scanty  and  highly  coloured.     Heart  sounds  normal. 

After  treatment  patient  went  to  sleep.  Treatment  henceforth 
three  times  a  day. 

August  30. — Patient  had  slept  fairly  well,  better  than  during 
any  night  since  the  27th  inst. 

Morning.  The  inflammation  had  spread  up  about  an  inch 
since  the  previous  evening.  Treatment  administered  with  in- 
creased energy. 

Afternoon.  The  bullte  larger.  The  inflammation  had  spread 
downwards  on  the  foot  about  half  an  inch  since  the  morning. 
The  original  scratch  becoming  lighter;  the  skin  around  it 
beginning  to  get  white.  The  spleen  still  very  tender,  but  the 
kidneys  not  so  much.     The  urine  still  dark. 

Evening.  The  inflammation  still  spreading  up  the  leg,  but 
only  slowly,  the  amount  being  about  one  inch  during  the  day. 
There  had  been  an  almost  entire  absence  of  rigors. 

August  31. — Morning.  Patient  had  slept  very  well  during  the 
night.  The  inflammation  had  spread  externally  to  about  the 
middle  of  the  external  condyle  of  the  femur ;  internally  it  had 
hardly  spread  at  all  during  the  last  twenty-four  hours ;  it 
extended  now  to  the  top  of  the  tibia.  Some  urine  passed  during 
the  morning  was  almost  normal  in  colour. 

Afternoon.  Most  of  the  bullae  opened  ;  no  new  ones  forming. 
The  inflammation  had  spread  externally  to  the  top  of  the  external 
condyle ;  internally  it  had  not  spread  at  all  during  the  day. 

Evening.  Leg  in  about  the  same  condition  as  during  the 
afternoon. 

Treatment  henceforth  twice  a  day. 

September  1. — Morning.  Patient  said  that  she  felt  better. 
Externally  the  inflammation  had  spread  up  nearly  to  the  middle 
of  the  thigh ;  internally  it  had  reached  the  lower  border  of  the 
patella.  Below  it  had  extended  over  the  whole  foot  and  reached 
the  toes.     The  whole  inflammatory  area  was,  however,  less  red 


296    ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

and  the  original  scratch  uuicli  ])aler ;  there  were  some  white 
patches  around  the  middle  of  the  lower  leg,  and  desquamation 
had  set  in.  No  new  bullae.  Urine  apparently  normal.  Motion 
for  first  tnne  since  August  27. 

Evening.  Patient  had  consumed  some  bread  and  milk  during 
the  day. 

September  2. — Morning.  Patient  had  slept  very  well.  The 
inflammation  had  spread  up  as  far  as  the  middle  of  the  thigh 
externally,  but  the  redness  from  the  knee  upward  was  fading 
away  ;  internally  the  inflammation  had  not  spread  at  all.  The 
white  patches  on  the  lower  leg  were  larger. 

Patient  ate  some  bread  and  butter  and  drank  some  miik,  and 
sat  up  most  of  the  day.     No  motion. 

Evening.  The  inflammation  had  not  spread  any  further,  and 
the  redness  was  paler.  Some  minute  new  bullse  were  forming 
on  the  outside  of  the  thigh.  Desquamation  was  proceeding  over 
the  greater  part  of  the  lower  leg,  and  had  begun  in  the  foot. 

September  3. — Patient  slept  very  well.  The  inflamed  area 
reached  its  maximum  size.  Above,  it  extended  externally  to 
about  the  junction  of  the  upper  and  middle  thirds  of  the  thigh, 
anteriorly  to  about  the  middle  of  the  thigh  ;  internally  to  about 
the  lower  border  of  the  patella,  posteriorly  to  about  the  junction 
of  the  lower  and  middle  thirds  of  the  thigh.  Below,  the  inflamed 
area  extended  over  all  the  toes. 

During  the  course  of  the  day  the  patient  ate  some  meat,  an 
egg,  and  some  bread  and  butter,  and  drank  some  milk.  One 
motion. 

Evening.  Inflammatory  area  the  same  size  as  during  the 
morning ;  lower  leg  pale  red  or  white  in  most  places.  The 
original  scratch  had  healed  up.  Desquamation  of  the  whole 
lower  leg  and  most  of  the  foot ;  the  latter,  however,  still  swollen. 
September  4. — Patient  had  slept  very  well.  Appetite  almost 
normal.  One  motion.  Patient  remained  up  most  of  the  day. 
Redness  in  the  thigh  continuing  to  fade.  Glands  in  inguinal 
region  only  about  half  the  size  they  were  when  I  first  saw  them. 

September  b. — Appetite  normal.  Patient  up  nearly  all  day. 
Eedness  further  diminished  ;  desquamation  on  the  thigh  had  set 
in.     Foot  still  swollen. 

September  6. — Foot  less  swollen.  Glands  in  inguinal  region 
no  longer  swollen.     One  motion. 


SPECIFIC    INFECTIOUS  DISEASES  297 

September  7. — Improvement  continued.  Desquamation  over 
the  whole  of  the  inflamed  area  in  the  thigh. 

From  to-day  onvi^ards  patient  up  all  day  and  walking  about 
as  usual. 

September  10. — Treatment  henceforth  only  once  a  day. 

September  12. — Only  slight  redness  of  the  thigh  left. 
Desquamation  finished  on  the  lower  leg,  but  still  actively  pro- 
ceeding on  the  thigh  and  foot.  Foot  hardly  swollen  any  more. 
Motion  daily  since  September  8. 

September  20. — Desquamation  finished.  Foot  not  swollen. 
Beyond  some  roughness  of  the  skin,  the  leg  normal.  Patient 
otherwise  normal.     Treatment  finished. 

The  knee-joints  and  hip-joints  remained  unaffected  through- 
out. The  ankle-joint  was  sometimes  a  little  painful  at  first,  but 
passive  flexion  and  extension,  together  with  traction  away  from 
the  lower  leg,  executed  through  a  small,  but  gradually  increasing 
radius,  removed  it  in  every  case  for  a  few  hours.  After  Sep- 
tember 5  the  ankle-joint  was  not  affected. 

The  heart  remained  unaffected  throughout. 

Trea  tmen  t. 

Is  conveniently  considered  in  three  sections  : — 

(1)  During  the  acute  stage. — I  treated  the  fever  in  the  usual 
way  by  head  exercise,  frictions  over  the  spinal  nerves,  kidneys  and 
spleen,  heart  and  side  shaking,  stomach  exercise,  &c.  On  the 
leg  the  movements  were  executed  in  a  direction  contrary  to  the 
venous  and  lymphatic  flow.  I  tried  by  means  of  centrifugal 
running  vibrations,  shakings  and  gentle  kneadings  given  over 
the  affected  part  of  the  leg  with  a  piece  of  lint  interposed  between 
it  and  my  fingers,  to  prevent  the  upward  spread  of  the  disease 
and  to  further  the  secretion  into  the  bullje.  The  consequence 
was  that  the  inflammation,  which  during  the  two  days  previous 
to  the  treatment  had  spread  right  up  the  lower  leg,  thereafter 
only  spread  an  inch  a  day  at  most.  In  addition  the  nerves  of 
the  leg  were  stimulated. 

(2)  During  the  subsiding  stage. — After  I  had  observed  that  the 
inflammation  had  not  spread  for  two  days  and  that  the  redness 
was  considerably  diminished,  I  used  passive  movements  at  the 
joints  of  the  leg  to  further  the  circulation.    The  intensity  of  these 


298      ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

movements  was  increased  day  b}'  day,  and  after  some  time  active 
movements  were  added  (about  September  8).  In  addition  nerve 
frictions  on  the  leg  and,  of  course,  tbe  constitutional  treatment 
were  used  throughout. 

(3)  During  the  convalescent  stage. —  Ordinary  treatment  for 
convalescence  after  fever. 

The  above  manipulations  on  the  leg  caused  but  little  pain  ; 
even  this  disappeared  after  the  fourth  day,  and  patient  began  to 
like  the  treatment  and  said  she  felt  it  did  her  good. 

I  saw  patient  again  on  October  6  of  the  same  year  (1900). 
She  was  very  well  and  the  only  abnormality  was  a  slight  rough- 
ness of  the  skin  of  the  right  leg.  On  October  20,  when  I  again 
saw  her,  this  had  disappeared.  During  August,  1902,  I  saw 
patient  for  the  last  time  ;  she  had  been  in  excellent  health  since 
our  last  meeting. 

Epidemic  Cerebro-Spinal  Meningitis. 

In  the  town  of  Huskvarna  instances  of  the  above  disease  were 
continually  being  notified;  during  the  summer  of  1899  there 
seemed  to  be  more  notifications  than  usual.  The  diagnosis  of 
the  following  case  was  not  absolutely  certain ;  the  case  might 
have  been  regarded  as  one  of  another  peculiar  form  of  fever 
which  is  endemic  to  the  town,  a  fever  with  no  special  symptoms 
beyond  cerebral  irritation,  lasting  from  six  to  eight  days  and 
ending  by  lysis  in  favourable  cases. 

Accounts  were  furnished  me  of  several  other  children  (living 
within  a  short  distance  of  the  patient  whose  case  I  am  going  to 
describe)  who  showed  nearly  the  same  symptoms,  and  who, 
after  lying  ill  with  high  fever,  great  irritation  and  occasional 
opisthotonos,  died  on  about  the  tenth  to  fourteenth  day  of  illness. 

E.  S.,  male,  aged  2^  years. 

Previous  Jiistonj. — Quite  good. 

History  of  iiresent  illness. — Patient  was  seized  on  August  2, 
1899,  with  sudden  fever  and  pain  in  the  head.  A  medical  man 
who  was  called  in  prescribed  antipyrin,  and  a  few  days  later 
camphor  and  antipyrin  ;  no  diagnosis  was  given.  On  August  18 
Dr.  A.  Moller  and  I  were  called  in. 

Examination. — Patient  lay  with  retraction  of  the  head,  photo- 
phobia, and  great  tenderness  over  the  skull  and  cervical  nerves. 


SPECIFIC    INFECTIOUS   DISEASES 


299 


Parents  said  they  had  occasionally  noticed  spasms,  and  once  a 
condition  of  opisthotonos ;  none  of  the  latter  symptoms  were, 
however,  manifested  during  our  visit.  Patient  seemed  quite 
conscious.     Pulse  172,  temperature  not  taken. 

Treatment. — Head  exercise,  spinal  nerve  frictions,  side  shak- 
ing, stomach  exercise  and  spleen  frictions,  &c. 

August  19. — Morning.  Condition  about  the  same.  Tempera- 
ture 103°.     Pulse  160.     Treatment  as  before. 

Afternoon.  Patient  worse,  semi-unconscious.  Pupils  some- 
what dilated,  great  tenderness  manifested  on  slight  percussion  of 


DATE 

19    20    El 

TIME 

A  E[M   EiM   E 

F° 

104' 
103" 
102" 

100' 

98" 
97" 
96  ■ 

A) 

(Ilia 

1 

! 

— 

4 

\ 

\ 

r 

y 

/ 

/ 

y 

the  head,  and  on  spinal  nerve  frictions.  Patient  occasionally  got 
somewhat  opisthotonic  and  threw  himself  about.  Temperature 
104°  (axilla),  10-5°  (rectum) ;  pulse  19'2,  irregular  (see  fig.  103). 

Treatment  as  before.  After  twenty  minutes,  temperature 
(axilla)  102'5°,  pulse  178,  and  patient  perspiring  very  much  ;  after 
another  forty-five  minutes,  temperature  (axilla)  101".5°,  pulse  172, 
and  patient  perspiring  a  good  deal. 

Evening,  temperature  98'6°,  pulse  90.     Treatment. 

August  20. — Temperature  during  the  morning  was  98"5°,  no 
treatment  was,  however,  administered  until  the  evening  ;  patient 
irritable ;  temperature  103'8°,  pulse  140.  After  treatment,  tem- 
perature 102'6°,  pulse  120. 

August  21. — Treatment  once.  Temperature  96'8°,  pulse  72. 
After  treatment,  temperature  96°,  pulse  65. 


300      ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

August  '2"2. — Treatment  once  during  the  evening.  Patient 
apparently  normal.     Temperature  99.4°. 

August  '23. — Appetite  returned  ;  patient  sitting  up  and  has 
been  walking  about ;  rather  weak,  but  otherwise  normal. 

August  24  to  28. — ^Treatment  once  daily  until  the  2Sth,  when 
it  was  finished.     Patient  normal. 

October,  1900. — Beyond  a  slight  cold  once  during  the  summer 
child  has  been  very  well  ever  since  illness. 


Rheumatic  Fever  and  Erythema. 

Kheumatic  erythema  and  rheumatic  fever,  occurring  in  myself, 
treated  May  to  July,  1902. 

Previous  history. — Before  marriage  my  father  suffered  from 
rheumatic  fever  which  left  a  mitral  lesion  and  subsequent  aortic 
incompetence ;  his  brother  died  of  rheumatic  fever,  and  one  of 
my  sisters  has  had  the  same  disease.  Personally,  I  have  had  the 
following  attacks :  1889,  rheumatic  fever ;  1893,  rheumatic  ery- 
thema ;  1895,  ditto ;  1897,  rheumatic  fever ;  1899,  rheumatic 
erythema  twice.  Between  the  above  attacks,  for  all  of  which  the 
manual  treatment  was  the  only  therapeutic  agent  employed,  I 
have  enjoyed  absolute  and  complete  immunity  from  rheumatic 
symptoms  of  any  kind,  and  have  never  felt  any  bad  effect  from 
wet  feet,  being  out  in  all  weathers  without  an  overcoat  and  in 
general  paying  no  particular  regard  to  damp,  rain,  or  cold. 

During  the  mouths  February  to  May,  1902,  I  had  an  excep- 
tional amount  of  work  to  do  ;  I  felt  that  it  was  becoming  too 
heavy  a  burden  and  that  I  was  losing  the  energy  and  strength 
necessary  to  administer  the  manual  treatment  for  twelve  or  more 
hours  a  day.  During  May  10  to  13  I  attended  almost  continu- 
ously a  patient  suffering  from  typhoid  fever ;  the  case  is  briefly 
described  in  the  appendix. 

History  of  present  illness. — May  13. — Slept  from  6  a.m.  until 
10.30  a.m.  ;  then  attended  to  my  practice  until  8  p.m.  Felt  very 
tired  all  day. 

May  14  and  15. — Felt  very  tired  but  worked  as  usual. 

May  16. — Slept  very  badly  and  awoke  with  pain  in  throat,  and 
difficulty  and  pain  in  swallowing.  On  examination,  pharynx, 
tonsils,  uvula  and  fauces  red.  I  worked  all  day  as  usual,  although 
I  felt  weak  and  tired.  During  the  evening,  temperature  101°, 
pulse  110  (for  temperature  see  separate  chart,  fig.  104). 


SPECIFIC   INFECTIOUS   DISEASES  301 

May  17.— Slightly  delirious  during  the  night  (I  easily  become 
so  when  feverish).  Slept  very  little.  Morning,  pulse  100.  Too 
ill  to  attend  to  my  practice.  During  the  course  of  the  day 
salivation  increased  (being  sometimes  blood-stained) ;  bloody 
mucus  on  blowing  the  nose.  During  the  evening  erythematous 
patches,  circumscribed,  raised,  tender,  and  with  a  well-defined 
margin,    appeared   on   the   legs.       A   large,    hard,    subcutaneous 


swelling  was  felt  on  the  flexor  aspect  of  the  right  forearm ;  it 
caused  little  pain,  but  a  good  deal  of  stiffness.  Great  swelling 
and  redness  of  the  penis,  and  a  soft,  well-defined,  movable,  boggy 
mass  (blood?)  manifested  itself  above  the  left  testicle,  inside  the 
scrotum.  Throat  about  the  same.  Urine  thick,  no  albumen. 
Pulse  100. 

May  18. — Delirious  during  the  night,  more  so  than  during  the 
previous   night.      Slept   very   little.      Throat   about   the   same ; 


302    ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

palate  very  red.  Neuralgic  pains  in  finger-tips,  back,  and  legs. 
Colour  of  penis  darker,  and  swelling  in  scrotum  smaller.  Erythe- 
matous patches  larger ;  some  new  ones  also  present. 

Morning,  pulse  80  ;  evening,  pulse  90. 

May  19. — No  delirium  during  night ;  slept  better.  General 
improvement  in  all  the  symptoms  :  swallowing  easier,  throat  less 
red,  erythematous  patches  smaller,  penis  regaining  normal  size. 

Ever  since  commencement  of  illness  I  had  got  up  as  usual, 
and  I  walked  about  in  ray  room  and  outside  in  the  open  air 
whenever  I  felt  able  to  do  so.  During  the  morning  of  this  day 
I  went  for  half  an  hoar's  drive,  and  during  the  afternoon  played 
billiards  for  an  hour. 

May  20. — Slept  well.  Much  better.  Resumed  my  medical 
practice  (see  below). 

Afternoon.  Swellings  of  left  fifth  metacarpal  and  left  cuboid 
bones,  which  were  hard,  rather  painful,  and  very  tender.  Throat, 
penis,   and  scrotum  practically  normal. 

May  21.— Slept  very  little. 

Morning.  Worse.  Swelling  oyer  fifth  metacarpal  had 
extended  to  cover  whole  of  back  of  hand ;  new  swellings  like 
the  last  over  the  right  knee  and  right  os  calcis.  Could  not 
walk  witliout  considerable  pain.  INIany  new  erythematous 
patches.      Throat  worse  ;    coughing  up  blood  at  intervals. 

Evening.  Managed  to  walk  about ;  this  improved  the  pain  so 
much  that  I  was  able  to  go  out  of  doors  for  half  an  hour's  stroll. 
All  symptoms  improved  during  the  course  of  the  day. 

May  22. — Slept  fairly  well.  All  swellings  and  erythematous 
patches  better,  but  a  new  swelling  present  in  the  flexor  aspect  of 
the  left  wrist  and  the  right  gastrocnemius.  Went  out  for  an  hour's 
walk  during  the  afternoon,  then  played  billiards  for  an  hour. 

May  23. — Slept  very  well.  General  condition  better,  but  both 
olecranon  processes  tender,  and  both  knee-joints  stiff.  Throat 
better.     I  only  coughed  up  very  little  blood  during  the  day. 

May  24.— Better. 

May  25. — About  the  same. 

May  26. — Several  of  my  patients  (including  one  case  of 
pulmonary  tuberculosis  in  the  third  stage),  who  had  been  com- 
pelled to  stop  treatment  during  my  illness,  having  become  so 
much  worse  for  want  of  it,  I  was  obliged  to  do  some  work  at  my 
practice,  otherwise  I  feared  that  some  fatal  results  might  occur. 


SPECIFIC    INFECTIOUS    DISEASES  303 

From  to-day  onwards,  until  May  29,  I  worked  about  two  hours 
in  the  morning  and  one  hour  in  the  evening. 

During  the  evening  of  Maj'  29  the  symptoms  of  rheumatic 
fever  set  in. 

During  the  course  of  the  afternoon  I  felt  uneasy  in  the  region 
of  the  heart.  I  began  to  feel  very  tired  indeed  at  about  7  p.m., 
and  at  8.30  p.m.  I  went  to  bed.  I  then  noticed  that  my  heart 
was  beating  very  irregularly,  and  that  its  action  was  becoming 
intermittent.  In  about  au  hour  my  condition  was  such  that  at 
every  beat  my  whole  bodj'  shook,  and  every  third  or  fourth  beat 
was  missed.  I  also  experienced  some  cyanosis  and  breathless- 
ness.  On  auscultating  my  heart,  a  loud  blowing  systolic  murmur 
was  heard  in  the  mitral  area,  also  great  irregularity  in  the  inten- 
sity of  the  heart  sounds.     Pulse  130  per  minute. 

I  had  administered  to  me  heart  vibration  and  shakmg  with 
frictions  on  the  left  fourth  and  fifth  dorsal  nerves  near  the  spine, 
together  with  stomach  exercise,  the  treatment  lasting  two  hours. 
In  consequence  m)'  heart  was  much  improved  and  the  iuter- 
•mittency  and  irregularity  almost  disappeared,  while  the  pulse 
was  reduced  to  108.     At  midnight  I  fell  asleep. 

May  30. — I  woke  at  3  a.m.,  with  the  heart  in  the  same  condi- 
tion as  during  the  previous  evening.  I  underwent  the  same 
treatment,  and  at  4  a.m.  the  heart  was  again  relieved.  Pulse  100. 
I  then  slept  again  until  8  a.m. 

8  a.m.  Awoke  with  great  stiffness  in  both  legs  and  right 
deltoid.  From  to-day  onwards  great  perspiration  during  sleep ; 
on  waking  up  I  generally  found  myself  drenched  with  sweat, 
which  had  a  bad  odour.  Urine  thick,  with  unpleasant  odour ; 
however,  it  contained  no  albumen  at  any  time  during  my  illness. 
Heart  better,  no  intermittencies  ;  more  regular,  and  the  murmur 
I  heard  yesterday  disappeared.  Pulse  112.  Temperature,  see 
separate  chart,  fig.  104. 

During  the  evening  both  feet  swelled  up  and  the  ankle-joints 
showed  the  typical  rheumatic  fever  swelling  ;  they  were  red, 
glazed  looking,  extremely  painful  and  tender ;  walking  was  very 
difficult.     Treatment  twice  a  day  henceforth  (see  p.  308). 

May  31. — Morning  worse ;  had  slept  very  badly.  Feet  very 
bad  ;  walking  almost  impossible. 

Evening.     Feet  slightly  better. 

June  1. — Morning.  Feet  improving,  but  left  knee  and  left 
shoulder  affected. 


304      ELEMENTS  OF  KELLGREN'S  MANUAL  TREATMENT 

Evening.  Knee  and  sLoulder  better,  but  left  wrist  very  bad, 
causing  intense  pain  for  two  hours  or  more.  Heart  quite  normal 
beyond  slight  acceleration  of  pulse. 

June  2. — Slept  about  three  and  a  half  hours  during  the  night. 

Morning.     Wrist  a  good  deal  better. 

Evening.  Eight  wrist  bad.  Before  going  to  bed  I  walked 
round  the  room  three  times ;  my  feet  were  still  so  bad  that  this 
quite  tired  me  out. 

June  3. — Morning.  Diarrhoea,  four  motions  during  the  day. 
Right  knee  very  bad  ;  I  could  not  walk  at  all. 

Evening.    Slightly  delirious  until  sleep  supervened  at  midnight. 

June  4. — Morning.  So  far  I  had  generally  spent  most  of  the 
night  in  an  armchair  ;  but  on  this  day  I  remained  in  bed  until 
8  a.m.  All  affected  joints  better,  and  no  new  ones  involved. 
General  feeling  of  stiffness,  and  mild  neuralgia-like  pains  in  the 
whole  of  body. 

Evening.  Better.  Slight  diarrhcea  from  to-day  onwards 
until  June  LI. 

June  5.  Slightly  delirious  during  night.  Morning.  Left  foot, 
left  shoulder  and  left  gastrocnemius  affected. 

Evening.     About  the  same. 

June  6. — Morning.  Felt  worse ;  ascribed  this  to  the  rainy 
weather,  as  hitherto  it  had  been  very  fine.     Right  knee  affected. 

Evening.  Daring  the  course  of  the  day  right  metacarpal  and 
right  second  and  fourth  toes  swollen.  At  about  10  o'clock  left 
acromio-clavicular  joint  became  bad  and  kept  nie  awake  all  night. 

June  7. — Morning.  Left  knee  and  whole  of  right  hand 
affected. 

Evening.     About  the  same. 

June  8. — Morning.  Right  hand  and  left  acromio-clavicular 
joint  worse.     Unable  to  write. 

Evening.  I  resumed  smoking  (one  cigar  a  day)  to-day,  having 
stopped  since  May  29. 

June  9. — Morning.     Left  knee  and  right  elbow  affected. 

June  10. — Morning.  Spent  all  night  in  bed  (had  not  done  so 
since  June  4),  and  did  so  from  to-day  onwards.  Both  knees,  both 
feet  and  left  hand  and  lumbar  portion  of  erector  spinas  affected. 

Evening.  Left  hand  very  bad  ;  stiffness  of  all  muscles  of 
right  side  of  the  neck. 

June  11. — Morning.    Left  hand  still  bad,  but  legs  nearly  well. 


SPECIFIC   INFECTIOUS   DISEASES  305 

Very  weak,  but  I  went  out  of  doors  for  a  walk  of  a  few  minutes 
for  the  first  time  since  May  30. 

June  12. — Morning.  Right  knee  bad.  During  the  afternoon 
I  went  out  for  about  fifteen  minutes. 

Evening.     Eight  sciatic  nerve  and  right  shoulder  affected. 

June  13. — Morning.  Worse  again.  Both  knees  and  right 
shoulder  very  bad.     Unable  to  walk. 

Evening.     Very  weak  all  day. 

June  14. — Morning.  Eight  hand  affected  ;  right  shoulder  still 
bad.     Able  to  walk  again. 

Evening.     Diarrhoea  stopped. 

June  15. — Slept  about  six  hours  during  the  night.  Shoulder 
still  bad. 

June  16. — About  the  same.  At  intervals  walked  up  and  down 
my  room  for  two  hours. 

June  17. — Slight  desquamation  of  hands  and  scrotum  had 
been  taking  place,  the  Jast  week.  Eight  shoulder  still  bad ;  during 
evening  right  hand  and  flexors  of  right  forearm  affected. 

June  18. — Both  shoulders  and  both  hands  bad.  Went  out 
during  the  afternoon  for  ten  minutes'  walk. 

June  19. — Eight  wrist  bad. 

June  20. — Left  wrist  and  left  knee  bad  ;  flexors  of  right  fourth 
finger  very  stiff  and  contracted.  Diarrhcea  again,  four  motions. 
AVeight  in  clothes,  85  kilos,  (it  was  103  in  April).  Went  out  for 
half  au  hour  during  the  afternoon.  Left  foot  bad  during  the 
evening. 

June  21. — Left  shoulder  affected,  all  other  joints  well. 

June  22. — Left  knee  and  ankle  and  right  elbow  affected. 
Played  the  piano  and  sang  for  an  hour  during  the  afternoon. 

June  23. — Left  knee  and  left  ankle  worse.  During  the 
evening  the  latter  better,  but  right  ankle  bad.  No  more  perspira- 
tion during  sleep. 

June  24. — Eight  shoulder  and  right  little  finger  affected. 
Went  out  during  the  afternoon  to  an  adjacent  villa  about  500 
yards  off;  took  forty-five  minutes  to  do  so.  Had  the  treatment 
administered,  and  walked  back  in  fifteen  minutes. 

June  25. — Getting  stronger.  All  joints  of  right  arm  bad,  but 
legs  feeling  very  well  and  much  stronger.  Out  for  two  hours 
during  the  day. 

June  26. — Hardly  any  joint  affected.  I  went  for  an  hour's 
20 


3o6  ELEMENTS   OF   KELLGREN'S   MANUAL    TREATMENT 

walk,  covering  a  distance  of  one  and  a  half  miles.  During  the 
evening  left  forefinger  very  bad. 

June  27. — Left  internal  malleolus  bad.  During  evening  right 
second  linger  very  bad. 

June  28. — Finger  very  bad  during  night,  keeping  me  awake 
until  5  a.m.     Eight  malleolus  bad  during  afternoon. 

June  29. — Treatment  once  a  day  henceforth.  Eight  shoulder 
bad ;  malleolus  better. 

June  30. — Stronger.     Left  shoulder  bad  during  afternoon. 

July  1. — Some  pain  in  both  shoulders,  but  none  elsewhere. 

July  2. — Left  shoulder  and  left  forefinger  bad.  Went  out  for 
ten  minutes'  walk  from  one  villa  to  another  in  pouring  rain ;  the 
temperature  was  9°  C,  and  a  fairly  strong  wind  was  blowing. 
Got  my  shoes  and  socks  damp  ;  no  bad  results. 

July  3. — Left  forefinger  affected ;  in  evening  left  second  finger 
affected. 

July  4. — Slight  stiffness  of  both  shoulders  and  feet.  Stopped 
taking  my  temperature. 

July  5. — Desquamation  of  hands  and  scrotum  finished. 

July  6. — AVent  out  for  a  walk  for  two  hours,  and  played 
billiards  for  an  hour  during  the  morning,  and  two  during  the 
afternoon  ;  also  took  a  drive  for  half  an  hour.  AVeight  in  clothes, 
87  kilos. 

July  7. — Getting  stronger  every  day.  Slight  stiffness  in  left 
foot.  Tried  to  dance  (waltz)  during  the  evening,  but  had  to  give 
up  the  attempt  very  speedily  through  giddiness. 

July  9. — My  appetite  for  the  last  four  or  five  days  had  been 
enormous ;  an  hour  after  a  heavy  meal  I  felt  as  if  I  could  eat 
another. 

July  10. — AVent  out  in  the  rain,  and  got  my  shoes  and  socks 
damp ;  no  bad  effects. 

July  13. — Some  stiffness  in  the  left  shoulder  during  the  last 
few  days  was  all  that  remained  of  my  rheumatism.  AVent  for 
a  ride  on  horseback  for  fifty  minutes.  AVas  caught  in  the  rain, 
and  wetted  through  to  the  skin.  On  coming  home  changed 
all  my  clothes. 

July  18. — Took  a  ride  of  two  and  a  half  hours  during  the 
afternoon.  On  coming  home  had  supper,  and  then  walked  about 
for  one  and  a  half  hours. 

July   23. — During   the   morning   I  treated  at  his  home  the 


SPECIFIC   INFECTIOUS  DISEASES  307 

patient  whose  case  is  found  described  on'pp.  339,  &.c. ;  from  this 
day  onwards,  until  August  1,  I  treated  him  at  his  home  every 
morning.  Took  a  ride  of  three  and  a  half  hours  during  the 
afternoon. 

July  27. — While  out  riding  I  got  absolutely  drenched  to  the 
skin.     Changed  my  clothes  on  coming  home. 

August  1. — Not  yet  as  strong  as  I  used  to  be,  but  otherwise, 
excepting  for  slight  stiilness  of  left  shoulder,  quite  normal. 
Commenced  working  at  my  practice  again,  this  occupying  me  for 
four  to  five  hours  per  day.     Weight,  95  kilos. 

August  2. — Bathed  in  the  neighbouring  lake  for  the  first  time 
since  taken  ill ;  temperature  of  water,  14°  C.    Treatment  finished. 

August  3. — Took  a  bic3'cle  ride  of  twenty-eight  miles,  the  last 
seven  miles  of  which  I  accomplished  in  thirty-five  minutes ;  felt 
no  bad  results  at  all. 

T)ratment. 

During  the  acute  stage  I  took  none  of  the  precautions  cus- 
tomary in  the  treatment  of  rheumatic  fever.  I  never  remained  m 
bed  all  day,  but  instead  got  up  and  walked  into  another  room 
if  possible,  even  though  doing  this,  with  the  help  of  two  other 
persons,  at  first  caused  very  acute  pain ;  and  every  now  and  then 
during  the  course  of  the  day  I  would  make  efforts  to  walk 
about  and  move  my  stiff  joints  ;  this  always  after  the  first  seconds 
diminished  the  stiffness  and  pain.  As  soon  as  the  weather  was 
warm  enough  I  went  out  of  doors. 

I  slept  in  a  cotton  night-shirt  between  sheets. 

My  diet  during  the  whole  period  up  to  about  July  1  (regardless 
of  fever),  was  about  as  follows: — Breakfast,  two  poached  eggs 
with  a  piece  of  dry  toast,  two  small  pieces  of  toast  with  jam  or 
marmalade,  and  a  pint  of  milk.  Dinner,  plate  of  soup,  ordinary 
sized  helping  of  meat  with  potatoes  and  vegetables,  followed  by 
fruit  and  cream  or  some  such  dish.  Supper,  meat,  potatoes, 
vegetables  and  glass  of  milk.  I  left  off  coffee  until  June  12,  after 
which  date,  in  addition  to  the  food  already  specified,  I  took 
during  the  course  of  the  afternoon  a  large  cup  of  coffee  with  some 
bread  and  butter,  a  few  biscuits,  &c. 

After  about  July  1  my  appetite  began  to  increase,  and  in  a 
few  days  became  enormous  (see  July  9).  About  the  end  of  July 
it  began  to  diminish  and  in  a  week  or  ten  days  was  normal  again. 


308  ELEMENTS    OF   KELLGREN'S    MANUAL   TREATMENT 

Gymnastic  treatment. — Vibrations  over  the  painful  joints 
and  passive  movements  combined  with  a  great  amount  of  trac- 
tion— without  this  they  would  have  been  quite  unbearable  on 
account  of  the  pain — frictions  on  the  nerves  leading  to  and  from 
the  affected  parts.  General  treatment  for  fever,  including  heart 
vibration  and  shaking.  My  kidneys  were  tender  during  the  whole 
course  of  the  fever. 

I  made  the  interesting  observation  on  myself  that  the  inability 
to  move  any  joint  from  pain  therein  did  not  always  depend 
entirely  on  the  local  condition.  For  example,  one  day  I  was 
unable,  on  account  of  the  pain  induced,  to  abduct  my  shoulder 
through  more  than  an  angle  of  4.5° ;  after  treatment  of  both  renal 
plexuses  (which  were  extremely  tender)  from  the  front,  I  could 
abduct  it  through  about  135°  with  very  little  pain.  On  another 
occasion  when  I  could  not  move  my  ankle-joint  a  painful  spot 
was  discovered  in  the  great  sciatic  nerve  of  that  leg  high  up, 
the  pain  in  it  almost  disapppeared  after  local  vibrations  and 
frictions  had  been  administered,  and  I  could  perform  the  move- 
ments at  the  ankle-joint  with  much  less  pain. 

During  convalescence  (on  and  after  July  1)  the  treatment  was 
as  follows  : — 

(1)  Sitting  arm  exercise,  PP,  AR. 

(2)  Heave  lean  standing  chest  expansion,  PA. 

(3)  Forwards  lying  back  exercise,  PP. 

(4)  Loin  lean  standing  alternate  rotation,  AR,  ringing,  PP. 

(5)  Stretch  stride  standing  bending  forwards,  PA. 

(6)  Half  lying  double  arm  rolling,  PP,  bending  and  stretching, 
AE. 

(7)  Half  lying  double  foot  rolling,  PP,  flexion  and  extension, 
AE. 

(8)  Side  lying  leg  lifting,  AE,  pressing  down,  PE,  side  length 
hacking,  PP. 

(9)  Stretch  grasp  toe  standing  hanging,  breathing,  PA. 

(10)  Half  lying  stomach  exercise,  kidney  frictions,  PP. 
Subsequent    history.  —  August,    1903. — A   slight    amount   of 

crepitus  can  be  felt  when  internal  rotation  of  the  left  humerus  is 
performed  ;  it  causes,  however,  no  pain  or  inconvenience.  Apart 
from  this  I  have  enjoyed  excellent  health  ever  since,  excepting 
that  a  slight  stiffness  in  the  left  knee-joint  occurred  in  January, 
1903,  for  a  period  of  three  days  ;  this  was  removed  by  appropriate 
treatment. 


SPECIFIC  INFECTIOUS   DISEASES 


309 


Erythema  Nodosum.* 

E.  S.,  male,  aged  four  years,  came  under  the  manual  treatment 
on  February  26,  1902. 

Previous  history. — Patient  had  never  been  very  strong  since 
his  birth,  and  had  always  been  very  backvs'ard  ;  for  example,  he 
did  not  begin  to  speak  until  two  and  a  half  years  of  age. 

History  of  present  illness. — During  the  last  fortnight  he  had 
been  looking  rather  pale  and  tired,  and  had  complained  of  head- 
ache and  also  pains  in  the  knees  and  right  side.     On  February  26 


=EB. 

MARCH 

DATE 

Z7\Z&\    1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

II 

12     I3| 

TIME 

mT 

M  E 

M   E 

M   E 

M   E 

M   E 

M   E 

M   E 

M    E 

M   E 

M   E 

M   E 

M   E 

M   E 

M   E 

106° 

ids' 

104.° 
103° 

102° 
101° 
100° 
99° 
98  ° 
97  ° 



Axi 

lla 

A 

t\ 

il 

1 

1 

) 

/ 

hl\ 

h 

A 

v 

V 

\^\ 

/ 

Ua 

^ 

\ 

r^ 

y^ 

L 

[^ 

L/ 

V, 

/• 

v^ 

PULSE 

132 

100 
132 

120 

135 

108 

120 

no 
120 

115 
126 

108 
118 

100 
120 

115 
116 

96 

100 

mo 
100 

no 
112 

too 

106 

102 

no 

100 

patient  remained  in  bed  most  of  the  day,  complaining  of  pain  in 
the  right  side.  I  saw  patient  during  the  evening  of  the  same  day. 
On  examination. — Tenderness  on  pressure  over  the  lower  ribs 
of  the  right  side,  but  no  pleural  friction  or  abnormal  lung  sounds. 
Temperature  and  pulse  normal.  I  administered  a  few  general 
strengthening  exercises,  together  with  vibrations  over  the  painful 
area  ;  the  pain  thereupon  disappeared . 

'  I  have  ventured  to  include  this  disease  in  this  chapter,  on  account  of  its 
relationship  to  rheumatic  fever  and  because  the  description  of  a  case  of  the  latter 
involved  describing  the  rheumatic  erythema  vrhich  preceded  it. 


3IO  ELEMENTS   OF   KELLGREN'S   MANUAL   TREATMENT 

February  27. — Morning.  Patient  looked  rather  ill,  but  said 
he  had  no  pain.  Great  tenderness  over  the  kidneys.  Treatment 
as  .before. 

Evening.     Patient  complained  of  pains  in  the  head  and  legs. 

Examination. — Several  typical  nodular  red  swellings,  num- 
bering about  fifteen  altogether,  were  visible  on  the  front  of 
both  lower  legs ;  these  swellings  were  oval,  elevated,  pale  red, 
about  a  half  to  one  inch  in  diameter,  and  painful  on  pressure. 
Very  great  tenderness  over  spinal  nerves  and  kidneys.  Fever 
(for  temperature  and  pulse  see  separate  chart,  fig.  105). 

Treatment. — General  treatment  for  fever,  including  special 
attention  to  the  spinal  nerves  and  kidneys. 

February  28. — Morning.     General  condition  improved. 

Evening.     No  new  swellings. 

March  1. — New  swellings  present,  one  on  right  knee,  two  on 
left  knee,  and  one  on  right  gluteal  region. 

March  2. — Morning.     Swellings  on  knees  disappeared. 

Evening.     New  swelling  on  right  forearm. 

March  3. — New  swelling  on  left  gluteal  region. 

March  4. — Swellings  on  right  leg  nearly  disappeared ;  those 
on  left  leg  brownish.  Some  new  swellings  on  back,  which  were 
slightly  tender. 

Evening.     More  swellings  on  back  of  forearm. 

March  5. — New  swelling  on  left  forearm  and  back  of  hand. 

March  6. — Swellings  fading.  General  condition  improved; 
patient  looking  much  better.     Less  tenderness  over  kidneys. 

March  8. — Swellings  disappeared.     Some  cough. 

March  22. — Patient  normal.  Treatment  finished.  Patient 
had  undergone  treatment  once  a  day  since  March  13 ;  previously 
he  had  been  treated  twice  a  day. 

During  the  whole  time  he  was  under  treatment  patient  was 
allowed  to  be  up  and  to  eat  what  he  liked. 

The  heart  remained  unaffected  throughout. 

Subsequent  history. — -I  saw  patient  again  in  September,  1902. 
He  had  continued  well  and  strong ;  and  both  his  parents  con- 
sidered him  to  be  in  much  better  health  than  before  his  illness. 


CHAPTER   lY. 

DISEASES    OF    THE    RESPIRATORY    ORGANS. 

Acute  Croupous  Pneumonia.' 

In  1847  Brantino;  successfully  treated  acute  pneumonia  by 
gymnastic  methods,  and  his  achievement  was  mentioned  by  him- 
self in  the  same  year,^  and  later  on  by  Georgii^  and  Hj.  Ling^ 
(see  also  Blundell'^).  His  attempt  was  not,  however,  repeated 
until  Henrik  Kellgren  made  another  essay.  Even  the  enthusiastic 
Neumann^  makes  no  mention  of  using  the  treatment  for  such 
cases,  otherwise  than  by  advocating  deep  respiration,  with, 
perhaps,  a  few  passive  movements  in  addition,  to  assist  the 
ordinary  course  adopted.  Neumann '  even  wondered  whether 
exudative  pleurisy  was  fitted  for  gymnastic  treatment;  from  this 
it  may  almost  certainly  be  deduced  that  he  would  regard  acute 
pneumonia  as  unfitted. 

Henrik  Kellgren  had  as  long  ago  as  1873  been  treating 
acute  pneumonia  successfully  by  means  of  gymnastic  methods ; 
and  his  successes  were  referred  to  by  Wretlind  *  and  Glatter ". 
Wretlind,  who  learnt  the  viodiis  operandi,  was  able  at  a  later 
date    to    test   its    efficacy   himself '".     About    1888-1890   several 

'  I  have  for  convenience  sake  included  pneumonia  amongst  diseases  of  the  respi- 
ratory organs  instead  of  placing  it  under  specific  infectious  diseases. 

■^Address  to  the  graduates  of  the  G.  C.  I.,  March  31,  1847. 

'"Kinetic  Jottings,"  1880,  p.  206. 

'Branting's  "  Efterlemnade  Skrifter,"  1882,  p.  xxvi. 

'  "  Medicina  Mechanica,"  1852,  p.  98. 

""Die  Athmungskunst,"  1857,  p.  103,  &c.  ;  and  Neumann  und  Schreher, 
■  •  Streitfragen  der  Deutschen  und  Schwedischeu  Heilgymuastik,"  1858,  p.  26. 

■"Referat  iiber  das  '  Erster  Bericht  iiber  das  Institut  flir  Schwedische  Heil- 
gymuastik und  Ortopedie  z\x  Wien,'  "  in  Athetieum  fur  Rationelle  Gymnastik,  1854, 
pp.  73-79. 

»"  Href  frau  Dr.  Wretlind,"  in  Hygiea,  Nov.,  1872— Feb.,  1873. 

■'  "  AUgemeine  Betraehtungeu  liber  den  Werth  der  Heilgymuastik,"  in  Wien.  Med. 
Prcsse,  1875,  No.  8. 

'"  See  "Om  Rorelsekuren  eller  Kinesitherapien,"  1874,  pp.  55,  56 ;  "Bokanmiilan," 
&o.,  in  Eira,  April  15,  1899,  p.  203 ;  "  Helsooch  Sjukvardsliira,"  1899,  p.  90. 


312   ELEMENTS   OF  KELLGREN'S   MANUAL    TREATMENT 

authors^  made  references  to  the  Kelln;ren  treatment  of  pneumonia. 
They  one  and  all  seemed  to  think  that  any  gymnastic  treatment 
for  this  condition  was  strongly  inadvisable.  Presumably  this  view 
was  the  outcome  of  the  knowledge  of  their  own  inability  to  do 
any  good  with  their  gymnastic  methods.  In  1890  Arvid  Kell- 
gren  ^  spoke  with  great  confidence  of  the  success  that  he  himself, 
and  his  brother  before  him,  had  had  in  applying  the  manual  treat- 
ment to  pneumonia.  During  the  last  ten  years,  as  far  as  I  know, 
nothing  has  been  published  on  the  subject. 

The  objects  of  the  manual  treatment  in  cases  of  pneumonia 
are  as  follows  : — 

(I.)  To  diminish  the  virulence  of  the  inflammatory  process  in 
the  lungs  by  raising  the  vital  activity  of  these  organs  and  remov- 
ing the  tension  by  promoting  the  venous  return.  This  reacts 
favourably  on  the  heart. 

(II.)  To  treat  the  constitution  as  a  whole. 

This  is  accomplished  by  : — 

(1)  Removing  the  impediments  to  respiration  which  lie  in  the 
muscular  apparatus.  These  are  found  to  be : — Contractions  in 
the  intercostal  muscles  over  the  affected  lobe  or  lobes ;  these  are 
removed  by  administering  vibrations  and  frictions  over  the  con- 
tracted areas  and  frictions  on  the  corresponding  dorsal  nerves 
simultaneously  (see  below).  Deficient  action  of  the  diaphragm, 
with  or  without  marked  contraction  of  the  abdominal  muscles  ; 
this  is  treated  by  means  of  vibration  and  shaking  in  the  subcostal 
and  suprapubic  regions,  subdiaphragmatic  suction  and  stomach 
exercise. 

In  addition,  these  impediments  can  to  a  great  extent  be 
removed  by  inducing  the  patient  to  respire  deeply.  Small  respi- 
rations must  be  taken  at  first,  and  the  volume  then  graduall}' 
increased ;  gentle  pressure  with  one  hand  on  the  abdomen  during 
expiration  will  greatly  facilitate  the  process. 


'See  KleeD,  "  Handbok  i  Massage,"  1888,  pp.  222,  223.  Gustafson,  "  Om 
Massage,  dess  Utfurande  och  Anv.iQdniiig,"  1888,  pp.  ii,  &c.  Nebel,  "  Bewegungs- 
kuren  mittelst  Si'-hwedischer  Heilgymnastik  und  Massage,"  1889,  page  184. 
Dollinger,  "Die  Massage  fiir  Aerzte  uud  Studirende,"  1890,  p.  158.  Hasebroek, 
'•  Die  Erschiitterung  in  der  Zanderschen  Heilgymnastik,"  1890,  p.  1. 

See  also  Hiinorfauth,  "  Handbuch  der  Massage,"  1887,  pp.  88,  89.  Dolega, 
"  Die  Massage,  ihre  Technik  und  Auveudung,"  1892,  p.  102.  Reibmayr,  "  Die 
Massage  und  ihre  Verwerthung,"  &c.,  1893,  p.  75. 

-  "  Techuic  of  Ling's  System  of  Manual  Treatment,"  1890,  p.  69. 


DISEASES    OF    THE  RESPIRATORY   ORGANS  313 

(2)  Eeinoving  the  impediments  to  respiration  that  He  in  the 
lungs  themselves.  This  is  partly  effected  by  restoring  the  muscular 
mechanism  to  its  normal  condition,  as  described.  In  addition, 
vibrations  are  executed  over  the  affected  areas  in  order  to  relieve 
the  congestion. 

(3)  Removing  the  impediments  to  respiration  that  lie  in  the 
pleura  (if  present)  by  administering : — Vibrations,  stationary  or 
running,  over  the  inflamed  pleura ;  this  will  promote  the  venous 
and  lymph  flow  and  remove  the  contraction  of  the  intercostal 
muscles ;  the  latter  will  react  favourably  on  the  former.  Frictions 
on  the  intercostal  nerves  supplying  the  affected  spaces.  Deep 
respiration ;  although  one  or  two  of  these  cause  an  increase  in  the 
pain,  yet  several  taken  successively  nearly  always  diminish  it  for 
some  hours  (see  expansion,  pp.  12-4,  &c.). 

(4)  Stimulating  the  nervous  elements  of  the  lungs.  Frictions 
are  executed  over  the  dorsal  nerves  near  the  spine  (see  p.  164)  ; 
the  nerves  on  the  affected  side  over  the  affected  lobes  are  always 
tender.  Frictions  should  be  executed  especially  over  those  nerves 
that  supply  the  intercostal  spaces  where  contractions  exist,  as 
already  described. 

(5)  Guarding  against  heart  failure  by  diminishing  the  resist- 
ance in  the  lesser  circulation  (as  mentioned  already),  and  by 
quieting  its  over-excited  action  through  heart  vibration  and 
shaking,  and  reflexly  through  stomach  exercise.  Frictions  over 
the  left  fourth  and  fifth  dorsal  nerves  near  the  spine  in  addition 
may  be  executed  while  applying  the  local  heart  treatment.  Better 
cardiac  action  brings  in  its  turn  improvement  in  the  lesser 
circulation. 

(6)  Treating  the  constitution  as  a  whole  by  means  of  head 
exercise,  cervical,  dorsal,  and  lumbar  nerve  frictions,  kidney 
frictions,  &c.  I  must  here  mention  that,  in  two  cases  of  pneu- 
monia I  have  treated,  the  kidney  region  of  the  affected  side  was 
much  more  tender  to  touch  than  that  of  the  opposite  side. 
Stomach  exercise  should  also  be  administered.  It  acts  bene- 
ficially by  reflexly  quieting  the  heart's  action  (as  already 
mentioned)  and  acting  depletingly  on  the  lungs. 

The  objects  of  the  manual  treatment  during  convalescence 
from  pneumonife  are  as  follows  : — 

(1)  To  improve  the  lungs  by  means  of  chest  clapping,  side 
shaking,  &c.,  and  by  means  of  active  respiratory  exercises. 


314  ELEMENTS   OF   KELLGREN'S   MANUAL    TREATMENT 

(2)  To  stimulate  the  nervous  elements  of  the  lungs  by  means 
of  dorsal  and  intercostal  nerve  frictions. 

(3)  To  improve  the  constitution  as  a  whole. 

K.  S.,  aged  33,  coachman,  moderate  drinker  of  alcohol,  came 
under  the  manual  treatment  on  March  28,  1900. 

Previous  history. — -Patient  always  well  and  strong  with  the 
exception  of  a  bad  attack  of  pnemrtonia  ten  years  previously. 

History  of  present  illness. — Patient  said  he  caught  a  chill  on 
March  24,  and  felt  rather  weak  for  the  next  few  days.  On 
March  27  he  drove  in  from  Sanna  to  Junkoping,  distance  about 
three  miles,  but  felt  very  weak,  had  a  shivering  attack  of  ten 
minutes'  duration,  and  was  obliged  to  go  home  at  once  and  take 
to  bed. 

March  28. — 1.30  p.m.  Patient  in  bed  ;  complained  of  severe 
headache.  Temperature  104'9",  pulse  140.  Nothing  abnormal  in 
lungs  or  heart.  I  administered  the  ordinary  treatment  for  fever. 
During  the  evening  I  paid  a  second  visit.  Patient  was  drowsy, 
and  I  did  not  examine  his  lungs  or  heart.  I  administered  a 
short  treatment,  and  he  said  he  would  go  to  sleep.  Tempera- 
ture 104-2°,  pulse  120. 

March  29. — Patient  had  slept  badly.  High  fever.  Tempera- 
ture 10.5"5°,  pulse  122,  respiration  41.  The  left  side  of  the  thorax 
did  not  move  quite  so  well  as  the  right  during  respiration,  which 
was  accelerated  and  shallow.  No  pain  on  deep  respiration.  There 
was  tenderness  over  the  fourth  to  eleventh  dorsal  nerves  near 
the  spine  on  the  left  side  ;  the  intercostal  muscles  in  the  fifth  to 
ninth  spaces  were  contracted.  On  percussion  there  was  some 
dulness  over  the  fourth  to  tenth  ribs  posteriorly  and  sixth  to 
eighth  laterally.  The  breathing  over  this  area  was  harsh 
vesicular,  and  some  fine  crepitations  were  audible.  No  sputum. 
Treatment  four  times  during  the  day.  For  temperature,  res- 
piration and  pulse  see  separate  chart,  fig.  106. 

March  30. — There  was  absolute  dulness  on  percussion  over 
the  left  lower  lobe  from  the  fourth  to  eleventh  ribs  posteriorly, 
and  sixth  to  ninth  ribs  laterally.  The  breathing  in  this  area  was 
tubular,  with  no  crepitations  unless  on  very  deep  inspiration,  and 
the  vocal  fremitus  and  resonance  in  it  were  markedly  increased. 

Treatment  three  times  during  the  day.  During  the  evening 
frothy  sputum. 


DISEASES   OF    THE   RESPIRATORY   ORGANS 


315 


March  31. — Patient  experienced  continued  great  pain  in  the 
left  half  of  the  thorax  over  about  seventh  and  eighth  ribs  in  the 
mammary  hne,  and  laterally  over  the  fifth  to  seventh  ribs.  The 
sputum  very  thick  and  here  and  there  streaked  with  blood. 

April  1. — General  condition  about  the  same  as  during  the 
previous  day.  The  spinal  nerves,  as  before  mentioned,  still  very 
tender.     Treatment  three  times. 

April  2. — Patient  wandering  in  his  mind  during  most  of  the 
day.  Sputum  now  partially  greenish,  and  streaked  with  blood. 
Treatment  five  times.  During  the  evening  patient  ate  a  little 
soup.  Since  March  28  he  had  taken  hardly  anything  except  a 
little  milk. 


MARCH 

APRIL 

DATE 

28  '     29           30      i      31       !       1        i       2       ^       3       1       4       1        5      1       6       1    7 

a 

9 

TIME 

A     EM  A    E 

MAE 

MAE 

M    A    E   M    A    E 

MAE 

M  A  e:m  A  E 

MAE 

M    E 

M     E 

M    E 

F" 

106' 
105' 
104" 
103" 
I02" 

100' 
99" 

98' 
97" 

A 

f\ 

(\ 

A. 

yt'j 

lA 

\ 

\ 

h 

\ 

/  ^ 

-  V, 

,__? 

'\ 

\ 

1 

\ 

/^ 

\       , 

l' 

\ 

1 

i 

Rectu 

1 

V 

,^ 

y 

\ 

PULSE 

123110,120  112  92105113  100112  115  IQOIIIO  116  116  116  112  120 
I40I201I22I25I02II2 121  104117  I2I06I30I24      !      112 

120 106  108 
104 108 

00  ISO  96 
14  100 

104 

00  104  100 

98            180   76|68  75 
98  108  88J           1 

80  70 

RESR 

\iZ  42  38J39  43  40|38  40  3843  43  40ft2  41  42t*0  40  46 

43  44  38 

fM  44  44 

40  38  36130  28|23  E4( 

20  16 

April  3. — Patient  wandering  in  his  mind  during  most  of  the 
day.  The  lung  symptoms  about  the  same,  but  less  pain  in  the 
side.     Treatment  six  times. 

April  4. — Pulse  dicrotic.  Herpes  labialis.  05  per  cent, 
albuminuria.  Patient  wandered  in  his  mind  until  about  G  p.m. ; 
then  he  recovered  his  senses,  and  temperature,  respiration,  and 
pulse  all  sank  somewhat.     (Pseudo-crisis.)     Treatment  six  times 

April  5. — Temperature  higher,  pulse  and  respiration  more 
rapid  again.  Patient  clear  in  his  head  during  most  of  the  day, 
excepting  the  morning.  '0.5  per  cent,  albuminuria.  The  tem- 
perature could  be  taken  again  properly ;    on  April  3  and  4  there 


3i6  ELEMENTS   OF   KELLGREN'S   MANUAL   TREATMENT 

had  been  great  difficulty,  as  patient  would  not  keep  still.  Treat- 
ment four  times. 

April  6. — -Patient  did  not  wander  in  his  mind  at  all. 
"1  per  cent,  albuminuria.  Patient  felt  very  sleepy  at  5  p.m.,  and 
began  to  perspire  very  much  indeed.  Crisis  commenced.  Treat- 
ment three  times. 

April  7. — Patient  slept  almost  without  stopping  until  8  a.m. 
He  then  woke  up  feeling  well,  but  very  weak.  He  perspired 
most  profusely  during  the  night ;  his  clothes  were  changed  several 
times  for  the  sake  of  dryness,  but  the  process  did  not  wake  him. 

Morning.  Temperature  98'8°,  pulse  80,  respiration  30.  The 
left  side  moved  somewhat  with  respiration ;  there  was  no  dulness 
on  percussion,  but  many  sounds  were  to  be  heard  over  the 
affected  area,  varying  from  fine  crepitations  to  coarse  ones. 
Appetite  good.  Patient  remained  in  bed  all  day.  Treatment 
twice.     The  spinal  nerves  already  referred  to  still  very  tender. 

April  8. — Some  fine  crepitations  to  be  heard,  otherwise  nothing 
marked.  Patient  got  up  and  said  tliat  he  felt  well,  though  weak. 
He  had,  however,  sufUcient  strength  to  walk  about  a  good  deal. 

April  9  to  10. — Treatment  twice.  Fine  crepitations  still 
audible  ;  patient  coughed  up  some  white  frothy  stuff. 

April  11. — Patient  went  out  of  doors  for  a  few  minutes. 
Treatment  once.     Lungs  normal.     No  crepitations ;  no  sputum. 

April  12  to  1-5.— Treatment  once  daily.  Patient  went  out 
during  the  15th  for  half  an  hour. 

April  16  to  22. — Treatment  once  daily.  During  the  22nd 
patient  did  several  odd  pieces  of  work,  such  as  carrying  window- 
frames  about,  taking  them  out,  &c. 

April  29. — Patient  drove  out  for  one  hour. 

May  1. — Patient  drove  out  one  and  a  half  hours  in  a  snow- 
storm.    He  said  that  he  felt  very  strong. 

May  9. — Patient  quite  well  and  strong.  Present  weight,  74| 
kilos.  He  stated  that  just  before  his  illness  he  weighed  74  kilos. 
Treatment  finished. 

July,  1903. — Patient  had  been  quite  well  ever  since  his  illness. 


Acute  Bronchitis. 

Mrs.  L.,  aged  27,  came  under  the  manual  treatment  on  Feb- 
ruary 28,  1900. 

Previous  history. — Patient  had  for  the  last  ten  years  had  a 


DISEASES  OF    THE   RESPIRATORY   ORGANS  317 

fairly  well  compensated  mitral  incompetence,  following  on 
rheumatic  fever. 

History  of  present  illness. — Patient  was  attacked  by  acute 
bronchitis  on  February  26,  1900 ;  she  could  not  assign  any  cause 
for  the  attack.  The  onset  was  fairly  sudden,  and  was  marked  by 
a  rigor.  Fever  set  in,  with  a  sense  of  oppression  in  the  chest, 
which  soon  gave  way  to  pain  behind  the  sternum,  and  a  cough 
came  on  which  increased  the  pain.  Pains  in  the  right  side,  arms, 
and  legs  also  made  their  appearance.  February  27. — General  con- 
dition worse  ;  secretion  from  bronchi  commencing.  February  28. 
— Patient  being  still  worse,  I  was  called  in. 

Examination. — Patient  complained  of  headache,  fever,  pains 
in  the  chest,  arms,  and  legs,  difficulty  in  breathing,  and  severe 
cough.  She  had  been  coughing  up  lumps  of  yellowish  matter  all 
day.  There  was  no  percussion  dulness.  On  auscultation,  loud 
bubbling  sounds  were  heard  all  over  the  chest,  and  these  were 
audible,  even  without  the  aid  of  a  stethoscope,  at  a  distance  of 
several  feet.  There  was  great  tenderness  between  the  scapulte. 
Temperature  103'5°,  pulse  110,  respiration  40.  Treatment 
forthwith  administered. 

March  1. — Treatment  twice  a  day  henceforth. 

Morning.  Temperature  108'2°,  pulse  103,  respiration  36. 
Headache  better. 

Evening.  Temperature,  104-2°  and  103-7°,  pulse  117  and  100, 
respiration  42  and  42,  respectively  before  and  after  treatment. 

March  2. — Morning.  Patient  better.  Temperature  102-8^  and 
102-4,  pulse  100  and  96,  respiration  38  and  36,  respectively 
before  and  after  treatment. 

Evening.  Less  bronchial  secretion.  Temperature  103-3°  and 
101-6°,  pulse  96  and  96,  respiration  36  and  38,  respectively  before 
and  after  treatment. 

March  3. — Patient  much  better ;  she  got  up  for  an  hour  or  so 
during  the  afternoon,  feeling,  however,  very  weak.  Less  bronchial 
secretion ;  hardly  any  headache ;  no  pains  in  arms  or  legs ; 
difficulty  in  breathing  only  when  patient  out  of  bed. 

Morning.     Temperature  101-3°  pulse  100,  respiration  28. 

Evening.  Temperature  102-8°  and  101-7°,  pulse  100  and  96, 
respiration  33  and  30,  respectively  before  and  after  treatment. 

March  4. — Patient  up  during  most  of  the  day.  Appetite 
returned  ;  ordinary  diet  resumed. 


3iS   ELEMENTS    OF   KELLGREN'S    MANUAL   TREATMENT 

Morning.     Temperature  lOOli^,  pulse  84,  respiration  23. 

Evening.     Temperature  100'8°,  pulse  93,  respiration  28. 

March  5. — Patient  stronger,  and  up  all  day.  Treatment  once 
only  during  the  morning.  Hardly  any  bronchial  secretion. 
Temperature  100'4°,  pulse  100,  respiration  20. 

March  6. — Patient  normal,  excepting  for  slight  weakness. 
Treatment  during  the  afternoon.  Temperature  99"7°,  pulse  88, 
respiration  20. 

March  7. — Patient  normal.  Temperature  98"6°,  pulse  68, 
respiration  18.     Treatment  for  the  last  time. 

June,  1902. — Patient  still  feeling  quite  well. 

Treatinent. 

Head  exercise,  thorax  vibration  and  shaking,  heart  vibration 
and  shaking,  side  shaking,  practising  deep  respiration,  stomach 
exercise,  vibration  over  the  bladder,  frictions  on  the  spleen, 
kidneys,  and  spinal  nerves,  specially  the  interscapular.  From 
March  5  onwards  chest  clapping  and  some  active  breathing 
exercises  in  addition. 


Acute  Pleurisy. 

Neumann  ^  was  doubtful  whether  exudative  pleurisy  should 
come  under  gymnastic  treatment,  as  advocated  by  Melicher.^ 
Hartelius,  in  1864,"  stated  that  "it  is,  of  course,  not  acute 
pleurisy,  but  only  the  more  or  less  severe  sequelae  that  can  be 
treated  by  gymnastics";  and,  in  1865,*  he  further  stated  that 
gymnastics  can  effect  nothing  if  an  exudation  remained,  together 
with  great  weakness  and  a  cachectic  condition.  In  his  handbook  ^ 
he  repeated  his  dictum  that  gymnastics  can  only  be  employed 
for  pleurisy  as  an  after-cure. 

The  manual  treatment  for  acute  pleurisy  during  the  acute 
stage  is  as  follows : — 


'  Quoted  on  p.  311. 

■  Cf.  Hj.  Ling,  in  Brantiug's  "  Efterlemnade  Slirifter,"  1882,  p.  xxvi. 
■■"'Om   Sjokgymnastiken  vid  Gymnastiska  Central  Institutet  under  ar  1863," 
1864,  p.  46. 

'"Gymnastiska  lakttagelser,"  1865,  p.  78. 

"'Laroboki  Sjukgymnastik,"  1870,  p.  245;  1883,  p.  258;  1892,  p.  251. 


DISEASES  OF    THE   RESPIRATORY  ORGANS  319 

(1)  Local. — This  has  already  been  described  under  pneumonia 
(see  p.   313;. 

(2)  General,  i.e.,  treatment  of  the  constitution  as  a  whole  by 
means  of  general  treatment  for  fever. 

During  the  convalescent  stage  it  is  as  follows : — 
(I)  Local. — -Movements  to  promote  the  circulation  of  the 
blood  and  lymph  in  the  pleura,  i.e.,  passive  manipulations  such  as 
vibrations,  hackings,  running  vibrations,  &c.,  over  the  affected 
parts  of  the  pleura ;  passive  trunk  flexions ;  active  trunk  flexions, 
unresisted  or  resisted. 

(•2)  General. — Treatment  on  the  lines  of  "  general  treatment 
for  convalescence." 

H.  S.,  male,  aged  1-5,  came  under  the  manual  treatment  on 
the  morning  of  November  19,  1900. 

Previous  history. — Quite  good. 

History  of  present  illness. — On  November  18  patient  was 
suddenly  attacked  with  rigors,  pain  in  the  right  side,  fever  and 
loss  of  appetite ;  he  remained  in  bed  all  day,  and  ate  nothing ;  and 
during  the  ensuing  night  slept  very  badly.  During  the  following 
morning  I  was  called  in. 

Examination. — Patient  complained  of  pain  in  the  right  side 
over  the  fourth  to  seventh  ribs  from  about  the  sternum  to  the 
anterior  axillary  line.  Coughing  and  attempting  deep  inspiration 
made  the  pain  much  worse,  so  that  patient  felt  as  if  a  knife  were 
cutting  him.  The  abdomen  did  not  move  at  all  with  respiration, 
and  the  right  half  of  the  thorax  only  moved  in  its  upper  part. 
The  movements  of  the  left  half  of  the  thorax  were  normal.  The 
intercostal  muscles  were  contracted  over  the  painful  area.  Auscul- 
tation, pleural  friction  over  the  fifth  and  sixth  interspaces  in 
about  two  inches  of  their  course  ;  breathing  harsher  in  type, 
expiration  more  audible  than  normal ;  fine  crepitations.  Urine 
high-coloured.  Temperature  103"6°,  pulse  11.5.  After  treatment 
less  pain,  temperature  103°,  pulse  110. 

Evening  of  same  day.  Pain  in  the  right  side  worse  than 
during  the  morning.  Great  tenderness  to  touch  over  the  fifth 
to  seventh  dorsal  nerves  on  the  right  side.  Pleural  friction 
more  intense  on  auscultation,  and  perceptible  to  the  fingers. 
Urine  still  darker  than  during  the  morning.  Temperature  103'4°, 
pulse  104.     After  treatment  temperature  103^,  pulse  102. 


320  ELEMENTS   OF  KELLGREN'S    MANUAL    TREATMENT 

November  '20. — Morning.  Patient  bad  slept  fairly  well. 
Still  a  good  deal  of  pain  in  the  side,  but  no  pleural  friction  to  be 
detected  on  auscultation.  Patient  cougbing  up  frothy  stuff 
streaked  with  blood.  Urine  very  dark.  Temperature  104°,  pulse 
102.  After  treatment,  pain  very  much  less,  temperature  103'5°, 
pulse  102. 

Evening.  Patient  still  coughing  up  frothy  stuff  streaked  with 
blood,  but  pain  in  side  much  less,  and  general  condition  improved. 
Respiration  partly  abdominal.  Patient  had  begun  to  eat  again. 
Temperature  102'2°,  pulse  88. 

Treatment  morning  and  evening. 

November  21. — Morning.  Patient  had  slept  very  well.  No 
more  cough  ;  very  little  pain  in  right  side.  Urine  clear.  Tem- 
perature 99'2°,  pulse  60. 

During  the  course  of  the  day  patient  got  up  and  felt  tolerably 
well,  although  weak. 

Evening.  Only  slight  pain  on  deep  respiration.  Temperature 
100-2°,  pulse  58. 

Treatment  morning  and  evening. 

November  22. — On  deep  respiration  patient  said  that  he  felt 
a  little  uncomfortable  in  his  right  side.  Bespiratory  movements 
normal.  No  fever  ;  temperature  and  pulse  normal.  Treatment 
once.     Patient  up  all  day. 

November  23. — No  treatment. 

November  24. — No  pain.  From  to-day  onwards  patient  was 
treated  once  a  day^  and  walked  to  and  from  his  home  to  my 
house,  a  distance  of  two-thirds  of  a  mile  each  way. 

November  2.5. — Slight  pain  returned  in  side.  It  finally  dis- 
appeared after  this  day's  treatment. 

November  26. — Patient  said  that  he  felt  much  stronger. 

November  27,  28  and  29. — Treatment.  On  29th,  patient  went 
back  to  his  work  as  engraver  at  Huskvarna  factory,  and  worked 
for  five  and  a  half  hours. 

November  30. — Patient  worked  at  factory  all  day,  excepting 
for  one  and  a  half  hours  during  which  he  walked  to  my  house, 
was  treated,  and  walked  back  again. 

December  2. — Patient  was  normal,  and  said  that  he  felt  quite 
strong.     Treatment  for  the  last  time. 

October,  1902. — Patient  had  been  very  well  ever  since  his 
illness. 


DISEASES  OF    THE   RESPIRATORY   ORGANS  321 

Chronic  Pleurisy. 

The  treatment  of  both  chronic  pleurisy  with  eiifusion  and 
chronic  dry  pleurisy  is  essentially  the  same,  the  objects  being  to 
remove  the  effusion  and  gently  break  down  the  adhesions,  and 
thereby  restore  the  normal  functions  of  the  pleura  and  respiratory 
apparatus. 

This  is  effected  by  means  of : — 

(I.)  Local  treatment,  ivhich  comprises  : — 

(1)  Stationary  vibrations,  shakings,  hackings,  &c.,  over  the 
affected  areas. 

(2)  Running  vibrations  and  frictions  from  before  backwards  in 
the  affected  intercostal  spaces. 

(3)  Nerve  frictions  on  the  posterior  divisions  of  those  spinal 
nerves  which  correspond  to  the  affected  spaces. 

(4)  Respiratory  exercises. 

(.5)  Lateral  trunk  flexions,  active  as  well  as  passive. 

(6)  Shaking  or  vibration  over  the  bladder. 

(II.)  General  treatment  of  the  constitution  as  a  whole. 

In  his  handbooks  of  1896,i  1899,^  1902,^  and  1903,^  Wide 
makes  the  astounding  statement  that  he  was  the  operator  to 
"introduce  gymnastics  into  new  spheres,  as,  for  example,  in  the 
after-treatment  for  acute  pneumonia  and  pleurisy."  This  asser- 
tion can  only  be  explained  by  a  complete  ignorance  on  his  part  of 
all  the  literature  on  Swedish  gymnastics,  for  cases  of  this  kind 
have  been  written  about  ever  since  1846.  Wide  must  have  over- 
looked even  the  productions  of  Dr.  Siitherberg,  formerly  head  of 
the  Gymnastic  Orthopaedic  Institute  in  Stockholm,  whose  very 
successor  Wide  himself  is  at  present. 

The  following  are  some  of  the  older  works  (up  to  1870)  that 
mention  either  convalescence  from  pneumonia  or  pleurisy,  chronic 
pleurisy  and  scoliosis  arising  from  the  latter,  as  having  been 
treated  by  gymnastic  methods. 

From  the  Gymnastic  Orthopaedic  Institute  : — 

Siitherberg.  "  Gymnastiskt-Ortopediska  Institutet  i  Stock- 
holm," 18.50,  pp.  4,  5,  &c. 

'  "  Handbok  i  Jledicinsk  Gymuastik,"  1896,  p.  210. 
■-"Handbook  of  Medical  Gymiiastics,"  1899,  p.  197. 
■' "  Handbok  i  Mediciusk  ooh  Ortopedisk  Gymnastik,"  1902,  p.  188. 
'  "Handbook  of  Medical  and  Orthopaedic  Gymnastics,"  1903,  p.  203. 
21 


322     ELEMENTS   OF   KELLGREN'S   MANUAL    TREATMENT 

Siitherberg.  "  Arsrapport  friin  Gymnastiska  Ortopediska  Insti- 
tutet  for  ar  1857,"  in  Hygiea,  November,  1858,  p.  641. 

Siitherberg.     "  Gymuastik  och  Ortopedi,"  1862,  p.  4. 

Siitherberg.  "  Gymnastiska  Ortopediska  Institutet,  dess  Stiill- 
ning  och  Verksamhet,"  1868. 

From  the  G.  C.  I.  and  other  practitioners  of  Ling's  system  : — 

Branting.  Speech  to  the  gi-aduates  delivered  on  April  1, 1846, 
quoted  by  Georgii,  "  Kinesitherapie,"  1847,  p.  99. 

Riecke.  "  Beitriige  zur  Heilung  der  Empyems  und  der 
Scoliose,"  in  v.  Walther's  und  v.  Ammon's  Zeitschr.  f.  Chir.  unci 
Augenheilk.,  vol.  vi.,  1846,  part  2. 

Puothstein.  "  Die  Gymnastik  nach  dem  Systeme  des  Schwed- 
ischen  Gymnasiarchen  P.  H.  Ling,"  1847,  p.  93. 

Eichter.  "  Organon  der  Physiologischen  Therapie,"  1850, 
p.  201. 

Branting.  "  Efterlemnade  Skrifter,"  1882,  in  section  devoted 
to  the  year  1851,  pp.  21,  23,  62,  &c. 

Neumann.     "  Die  Heilgymnastik,"  1852,  p.  287. 

Mehcher.     "  Erster  Bericht,"  &c.,  1853. 

Eulenberg.     "  Die  Schwedische  Heilgymnastik,"  1853. 

Melicher.     "  Jahresbericht  flir  1853,"  1854. 

Eichter.  "  Bericht  iiber  neuere  Heilgymnastik,"  in  Schmidt's 
Jahrbucher,  1854,  vol.  Ixxxii.,  pp.  248,  251. 

Friedrich.  "  Die  Heilgymnastik  in  Schweden  und  Norwegen," 
1855,  p.  41. 

Neumann.  "  Die  Einfiihrung  der  Heilgymnastik  in  Lazareth 
und  Khnik,"  in  Athcn.f.  Bat.  Gi/m.,  vol.  ii.,  1855,  part  1,  p.  1. 

Melicher.     "  Jahresbericht  fiir  1854,"  1855. 

Weber.  "  Einige  Worte  iiber  den  Werth  .  .  .  der  Heil- 
gymnastik," in  Athen.f.  Bat.  Gym.,  vol.  iii.,  1856,  part  2,  p.  89. 

Melicher.     "  Jahresbericht  fiir  1855,"  1856. 

Melicher.     "  V.  Jahresbericht  fur  1856  und  1857,"  1858. 

Eichter.  "  Bericht  iiber  neuere  Heilgymnastik,"  in  Schmidt's 
Jahrbucher,  1858,  vol.  xcviii.,  p.  126. 

Steudel  and  Giirtner.  "  Dritter  Bericht  uber  das  Heilgym- 
nastische  Institut  in  Stuttgart,"  1858,  p.  23. 

Ulrich.  "Jahresbericht  iiber  das  Institut  fiir  Schwedische 
Heilgymnastik  in  Bremen,"  1858,  pp.  38  Sc  64. 

Mehcher.     "  VI.  Jahresbericht  fiir  1858  und  1859,"  1860. 

Eichter.  "  Grundriss  der  Inneren  Klinik,"  1860,  vol.  ii.,  pp. 
239,  248,  252. 


DISEASES   OF    THE  RESPIRATORY   ORGANS  323 

Branting.    "  Arsrapport     .    .    .    ar  1861,"  p.  30.. 

Branting.     "  Arsrapport,"  &c.,  1863,  pp.  29,  &c. 

Nycander.  "  Aarsberetning  fra  Institutet  for  Svensk  Medi- 
cinsk  Gytnnastik  i  Kjobenhavn,"  1863,  pp.  14-16. 

Hartelius.  "  Om  Sjukgymnastiken  vid  Gyiunastiska  Central 
Institutet  under  ar  1863,"  1864,  pp.  44,  78. 

Hartelius.     "  Gymnastiska  lakttagelser,"  1865,  p.  77. 

Hartelius.  "  Arsberiittelse  i  Sjukgymnastik,"  &c.,  in  Svenska 
Gyvinnstik-Fdrenigens  Tidskrift,"  1866,  p.  49. 

Hartelius.  "  Gymnastiska  Notiser,"  1870,  p.  6.  "  Larobok  i 
Sjukgymnastik,"  1870,  p.  245. 

Case  1. 

E.  M.,  female,  aged  26  years,  domestic  servant. 

Previous  history. — Quite  good. 

History  of  present  illness. — Patient  on  October  19,  1901,  was 
attacked  with  violent  stabbing  pains  in  the  right  side,  accom- 
panied by  fever,  rigors  and  perspiration.  She  managed  to  keep  up 
for  a  week,  but  was  then  compelled  to  take  to  her  bed.  No 
medical  aid  was  summoned  until  seven  weeks  after  the  onset  of 
the  illness ;  this  was  in  part  due  to  the  fact  that  patient  lived  in 
the  country  many  miles  away  from  any  member  of  the  profession. 
At  last,  when  aid  arrived,  a  diagnosis  of  effusion  into  the  right 
pleura  was  made,  and  patient  was  recommended  to  the  hospital 
in  Jonkoping.  Two  days  afterwards  she  was  admitted  to  the 
latter  institute,  and  she  remained  there  until  January  16,  1902. 
Five  punctures  were  made  at  different  times  into  the  right  pleura, 
but  no  effusion  was  found.  Patient  slowly  became  better,  and  on 
leaving  she  was  recommended  gymnastic  treatment. 

Patient  consulted  me  on  February  3,  1902. 

Examination. — Patient  complained  of  a  continued  sense  of 
constriction  and  pain  in  the  whole  right  side  of  the  thorax.  This 
pain  was  only  slight  on  ordinary  respiration,  but  deep  respira- 
tion very  much  aggravated  it,  so  that  sharp  stabbing  pains  were 
experienced.  She  also  complained  of  constant  pain  down  the 
right  side  of  the  spine,  from  the  second  to  the  twelfth  rib, 
about  an  inch  from  the  middle  line. 

The  right  side  of  the  thorax  moved  much  less  with  respiration 
than  the  left  ;  on  deep  inspiration  the  distance  from  the  xiphister- 


324     ELEMENTS   OF   KELLGREN'S   MANUAL    TREATMENT 

num  horizontally  backwards  to  the  spinous  process  of  the  corre- 
sponding vertebra  was  36 J  cm.  on  the  right  side,  as  compared  with 
39  cm.  on  the  left.  On  percussion  of  the  right  side  there  was 
dulness,  almost  absolute,  posteriorly  from  the  third  to  the  tenth 
ribs  for  about  three  to  four  inches  external  to  the  vertebral 
column,  and  anteriorly  in  the  clavicular  and  mammary  regions. 
Over  the  rest  of  the  right  thorax  the  note  was  partially  impaired. 
Pleural  friction  could  be  heard  almost  everywhere  in  the  right 
thorax,  the  amount  varying  from  "creaking  leather"  sounds  to 
"  fine  friction."  In  some  cases  the  friction  was  palpable.  The 
breath  sounds  and  vocal  resonance  were  diminished  over  the 
whole  right  thorax,  and  in  places  the  former  were  either 
inaudible  or  else  masked  by  pleural  friction. 

Treatment. 

(1)  Heave  grasp  standing  chest  clapping,  side  shaking,  PP. 

(2)  Half  lying  double  arm  rolling,  PP,  bending  and  stretch 
ing,  AK. 

(3)  Stretch  stride  standing  bending  forwards,  PA,  with  back 
hacking,  PP. 

(4)  Forwards  lying  back  exercise,  PP. 

(5)  Hip  lean  walk  standing  lateral  flexion,  PE,  extension,  AE. 

(6)  Loin  lean  stride  standing  alternate  rotation,  AE,  ringing, 
PP. 

(7)  Eight  stretch  left  side  lying  running  nerve  frictions, 
including  the  intercostal  nerves,  PP,  side  length  hacking,  PP. 

(8)  Walk  standing  double  arm  circling,  breathing,  PA. 

(9)  Half  lying  vibration  over  the  right  thorax,  especially  the 
most  affected  parts  or  where  pain  was  felt  most,  with  running 
vibrations  along  the  intercostal  spaces,  PP. 

(10)  Half  lying  stomach  exercise,  PP. 

(11)  Stretch  grasp  toe  standing  hanging,  breathing,  PA. 
Progress. — Pain  was   experienced  by  the  patient  in  various 

parts  of  the  right  thorax  for  the  following  three  weeks,  the  locali- 
ties of  the  pain  generally  differing  from  day  to  day. 

February  '20. — The  pain  along  the  side  of  the  spine  had  dis- 
appeared. 

March  4. — -Patient  very  much  better.  Pleura  normal  except 
over   third   to    fifth   interspaces    under    mammary   gland   where 


DISEASES   OF    THE  RESPIRATORY   ORGANS  323 

friction  was  heard  ;  the  friction  was,  however,  not  loud,  and 
normal  breath  sounds  were  audible  in  this  area.  On  deep  inspi- 
ration, circumference  of  right  lung,  38  cm.,  left  lung,  39^  cm. 

April  4. — Pleura  normal,  no  friction.  On  deep  inspiration, 
circumference  of  both  sides,  40  cm.     Treatment  finished. 

During  July,  1902,  I  heard  that  patient  was  still  keeping 
quite  well. 

Case  2. 

A.  F.,  male,  aged  4.5,  worker  in  an  iron  factory. 

Previous  history. — Very  good  indeed. 

History  of  present  illness. — Patient  went  through  an  attack  of 
pleurisy  with  effusion,  which  commenced  December  24,  1901 ; 
he  stated  that  he  had  fever  for  sixteen  days,  and  was  kept  to  bed 
for  a  month.  He  was  then  allowed  up,  but  was  so  weak  that  he 
could  not  walk.  About  the  middle  of  February,  1902,  he  was 
allowed  out  of  doors  for  five  minutes  a  day,  during  the  next  week 
for  ten  minutes  a  day,  and  so  on,  gradually  increasing  the  time  ; 
by  March  8  he  was  strong  enough  to  take  a  walk  of  two  miles. 
On  March  20  his  medical  man  recommended  him  to  me  for 
gymnastic  treatment. 

Examination. — March  21,  1902.  Patient  complained  of 
continued  feeling  of  heaviness  and  tiredness  in  the  left  half  of  the 
thorax,  and  difficulty  on  respiration.  No  pain  on  deep  respira- 
tion, but  only  a  sense  of  uneasiness  in  the  left  side.  Intercostal 
spaces  of  left  side  of  thorax  somewhat  indrawn,  and  the  whole 
left  side  remained  immobile,  even  during  deep  respiration. 
Circumference  of  left  half  41  cm.,  both  during  deep  inspiration 
and  deep  expiration,  as  compared  with  44  cm.  and  42^  cm.  on  the 
right  side.  Posteriorly,  absolute  dulness  on  percussion  from  the 
fourth  rib  down  to  the  base  of  the  lung,  and  the  same  in  the 
axilla ;  anteriorly,  the  dulness  extended  round  so  as  to  blend  with 
the  cardiac  dulness.  Vocal  fremitus  and  resonance  almost  absent 
over  this  area ;  no  breath  sounds  heard  over  it.  Plem-al  friction 
in  third  and  fourth  interspaces  posteriorly,  in  fifth  and  seventh 
laterally,  and  fifth  and  sixth  anteriorly.  Some  crepitations  at 
both  apices.  Heart  sounds  closed,  though  muffied  in  the  mitral 
area.  General  weakness  and  emaciation.  Appetite  poor.  Ten- 
dency to  free  perspiration. 


326     ELEMENTS  OF   KELLGREN'S    MANUAL    TREATMENT 

Treatment. 

(1)  Heave  grasp  standing  chest  clapping,  PP,  side  shaking,  PP. 

(2)  Hip  lean  walk  standing  lateral  flexion,  PR,  extension,  AR. 

(3)  Half  l}'ing  double  arm  rolling,  PP,  bending  and  stretching, 
AE. 

(4)  Forwards  lying  back  exercise,  PP. 

(5)  Left  stretch  right  side  lying  running  nerve  frictions,  PP, 
side  length  hacking,  PP. 

(6)  Eide  sitting  alternate  rotation,  AE,  ringing,  PP. 

(7)  Halt  lying  vibration  over  left  half  of  thorax,  and  running 
intercostal  vibrations,  PP. 

(8)  Half  lying  stomach  exercise,  vibration  over  the  bladder,  PP. 

(9)  Stretch  grasp  toe  standing  hanging,  breathing,  PA. 
Progress. — March  22.     The  left  side  beginning  to  move  with 

respiration,  and  patient  stated  that  he  breathed  more  easih'. 
Deei3  inspiration,  however,  had  for  the  last  week  caused  stabbing 
pains  in  the  left  side  of  the  thorax,  the  site  of  these  pains  varying 
from  day  to  day. 

April  10. — The  left  side  moved  fairly  well  with  respiration, 
the  circumferences  being  41  cm.  and  42^  cm.  as  compared  with 
41  cm.  and  41  cm.  on  March  21.  Partial  dulness  posteriorly 
from  the  seventh  rib  downwards ;  laterally  the  note  somewhat 
impaired  below  the  seventh  rib ;  anteriorly  no  dulness.  Vocal 
fremitus  and  resonance  more  marked  in  these  areas  than  before, 
and  pleural  friction  now  audible  all  over  them.  On  deep  respira- 
tion the  inspiratory  breath  sounds  audible.  The  crepitations  at 
the  apices  had  disappeared.  No  muffling  of  the  sounds  in  the 
mitral  area.  General  condition  considerably  improved ;  patient 
stronger,  and  reported  his  appetite  to  be  once  more  normal. 

May  4. — Patient  had  commenced  to  work  again  four  hours 
a  day  in  the  factory. 

May  15. — Treatment  finished.  The  stabbing  pains  referred 
to  above  almost  disappeared.  No  difficulty  in  breathing,  except 
after  considerable  exertion.  Expansion  of  left  side  very  good,  the 
circumferences  being  42  cm.  and  44  cm.,  as  compared  with  43  cm. 
and  46  cm.  on  the  right  side.  Posteriorly  and  laterally  the  partial 
dulness  referred  to  on  April  10  had  almost  disappeared,  the  note 
being  but  slightly  impaired.  Vocal  fremitus  and  resonance 
posteriorly  almost  as  plain  as  on  the  right  side.     Some  pleural 


DISEASES   OF    THE   RESPIRATORY   ORGANS  327 

friction  heard  posteriorly,  but  causing  the  patient  no  inconveni- 
ence beyond  a  sense  of  uneasiness  from  time  to  time.  Breath 
sounds  normal.  Patient  said  that  he  felt  qaite  strong  again.  He 
proceeded  to  resume  his  full  day's  work  (nine  hours  a  day)  at  the 
factory. 

August  16. — I  saw  patient  again.  He  had  been  working  full 
time  ever  since  he  finished  the  treatment.  The  slight  feeling  of 
uneasiness  referred  to  on  May  15  was  still  occasionally  felt,  other- 
wise no  abnormal  subjective  sensations.  Condition  of  pleura 
showed  no  further  change. 

Case   8. 

E.  J.,  aged  16,  domestic  servant,  came  under  the  manual 
treatment  on  July  7,  1902. 

Previous  history. — Not  very  good.  Patient  had  never  been 
very  strong.  She  had  rheumatic  fever  about  four  years  pre- 
viously, which  left  her  with  a  mitral  incompetence.  This, 
however,  was  quite  well  compensated,  and  had  not  given  her 
any  trouble. 

History  of  jrresent  illness. — Patient  was  attacked  with  pleurisy 
in  the  right  side  on  May  22,  1902.  Her  medical  man  never  said 
anything  about  there  being  an  effusion,  and  no  punctures  were 
made.  She  was  kept  in  bed  for  two  weeks,  after  which  she  was 
allowed  up  a  little.  At  the  end  of  a  month  she  had  so  far 
recovered  as  to  be  allowed  out  of  doors,  although  she  was  still 
weak,  and  had  a  great  sense  of  opjjression  and  tiredness  in 
the  right  side.  Her  condition  improved  only  very  slightly  after 
that  until  July  7,  1902. 

Examination. — Patient  thin  and  pale,  complaining  of  weak- 
ness and  continued  feeling  of  heaviness  and  tiredness  in  the  right 
side.  The  right  side  moved  only  slightly  with  respiration ;  on 
deep  expiration  the  circumference  was  32  cm.,  and  on  deep  inspir- 
ation 32^  cm.,  as  compared  with  31  cm.  and  33  cm.  on  the  left 
side.  There  was  absolute  dulness  on  percussion  posteriorly  from 
the  fourth  rib  downwards,  and  in  the  axilla  from  the  sixth  rib 
downwards,  the  area  of  dulness  fading  off  on  proceeding  forwards, 
and  terminating  about  an  inch  in  front  of  the  anterior  axillary 
line.  Pleural  friction  was  audible  along  the  limits  of  the  dull 
area,  but  not  in  the  area  itself,  where  there  was  complete  absence 


328     ELEMENTS   OF   KELLGREN'S    MANUAL    TREATMENT 

of  vocal  fremitus,  vocal  resonance  and  breath  sounds.     There  was 
no  aegophony. 

Treatment. 

(1)  Forwards  lying  back  exercise,  PP. 

(2)  Heave  grasp  standing  chest  clapping,  PP,  side  shaking,  PP. 

(3)  Stretch  side  standing  bending  sideways,  PA,  given  with 
hacking  over  the  affected  area  on  the  right  side,  PP. 

(4)  Reach  grasp  stoop  fall  standing  double  elbow  flexion  and 
extension,  PA,  with  back  hacking,  PP. 

(5)  Stretch  half  lying  running  nerve  frictions,  including  the 
intercostal  nerves,  PP,  side  shaking,  PP. 

(6)  Half  lying  chest  vibration  given  specially  over  the  affected 
areas,  PP. 

(7)  Half  lying  stomach  exercise,  shaking  over  the  bladder, 
kidney  frictions,  &c.,  PP. 

Progress. — Patient  began  after  a  few  days  to  feel  sharp 
stabbing  pains  in  the  right  side  of  the  thorax,  the  site  of  these 
varying  from  day  to  day.  Pleural  friction  was  audible  over  the 
whole  dull  area  on  and  after  July  20. 

August  7. — The  dulness  had  diminished  in  extent,  the  upper 
limit  being  the  sixth  rib  posteriorly,  and  it  was  now  only  partial, 
not  complete.  There  was  no  dulness  in  the  axilla.  Pleural 
friction  and  faint  breath  sounds  were  audible  in  the  whole  dull 
area,  and  also  in  the  axilla  where  the  dull  area  used  to  be. 

August  21. — The  expansion  of  the  right  side  of  the  chest  was 
as  good  as  that  of  the  left,  the  figures  being  32^  cm.  and  34^  cm. 
on  both  sides  on  deep  expiration  and  deep  inspiration  respectively. 
A  slightly  dull  area  about  three  inches  wide  was  found  posteriorly 
from  the  eighth  rib  downwards  ;  the  vocal  fremitus  and  resonance 
were  heard  almost  as  well  here  as  in  the  corresponding  area  on 
the  left  side  ;  the  breath  sounds  were,  however,  somewhat  fainter 
on  the  right  side.  There  was  no  more  pain  or  pleural  friction 
anywhere.  Patient  looked  much  better,  and  said  that  she  felt 
quite  well  and  strong.  Although  not  quite  cured,  patient  had  to 
finish  treatment,  otherwise  she  would  have  lost  her  situation. 

Further  progress  unknown. 

Case  4. 

S.  W.,  male,  aged  26,  worker  in  Huskvarua  factory,  came 
under  the  manual  treatment  on  April  4,  1902. 


DISEASES  OF   THE   RESPIRATORY   ORGANS  329 

Previous  historij. — Patient  bad  never  been  very  strong  ;  had 
always  had  a  narrow  chest  and  been  very  thin. 

Historij  of  present  illness. — During  January,  1897,  patient 
suffered  an  attack  of  pleurisy  in  his  left  side,  which  confined  him 
to  his  bed  for  a  month.  The  medical  man  who  attended  him 
made  no  punctures,  and  patient  was  never  told  whether  he  had 
an  effusion  or  not.  The  result  of  the  pleurisy  was  that  the  left 
side  became  indrawn  and  concave  at  its  lower  part,  and  a 
scoliosis  resulted.  When  patient  was  allowed  up  he  was  very 
weak,  and  it  took  three  months  before  he  was  strong  enough 
to  resume  work  again.  He  underwent  two  months'  gymnastic 
treatment  according  to  Ling's  system,  but  stated  that  the  course 
only  did  him  very  little  good.  Since  then  (June,  1897)  his 
condition  had  remained  the  same. 

Patient  consulted  me  on  April  4  for  catarrh  of  both  lungs 
(non-tubercular).  I  considered  the  lung  condition  amenable  to 
the  manual  treatment,  and  recommended  patient  to  take  a  longer 
course  of  treatment  than  was  necessary  for  the  cure  of  his  lungs, 
in  order  to  obtain  an  amelioration  in  the  condition  of  his  pleura 
and  in  his  scoliosis. 

Examination. — Patient  had  suffered  from  a  good  deal  of  cough 
for  the  last  three  months,  and  had  been  perspiring  at  night  and 
getting  thinner  during  the  last  two  months,  and  he  had  been 
getting  progressively  weaker,  having  to  cease  work  at  the  end  of 
February,  1902.  He  complained  of  a  continued  heavy  feeling  in 
the  left  side  of  the  thorax  low  down,  with  stabbing  pains  if  he 
either  bent  his  trunk  over  to  the  right  side  or  stretched  up.  No 
pain  was,  however,  felt  in  the  area  mentioned  dm'ing  deep 
inspiration. 

There  was  considerable  emaciation  of  the  whole  body.  A 
C-shaped  scoliosis  with  the  concavity  to  the  left  commenced  at 
the  first  dorsal  vertebra  above  and  extended  to  the  first  lumbar 
vertebra  below.  A  straight  line  drawn  between  the  spines  of 
these  vertebras  was  5  c.  distant  from  the  spines  of  the  fifth  and 
sixth  dorsal  vertebrae,  where  the  point  of  maximum  curvature  is 
situated.  The  muscles  011  the  concave  (left)  side  of  the  curvature 
were  hard  and  contracted,  those  on  the  convex  (right)  side  soft 
and  flabby.  By  means  of  voluntary  effort  the  curvature  could  be 
slightly  straightened  so  that  its  maximum  point  was  only  about 
41-  c.  from  the  line  drawn  between  the  spines  of  the  first  dorsal 
and  first  lumbar  vertebrae. 


330     ELEMENTS    OF   KELLGREN'S   MANUAL    TREATMENT 

Left  side  of  the  thorax.  The  whole  side  was  markedly  con- 
cave, the  point  of  maxiniuiu  curvature  being  at  the  sixth,  seventh 
and  eighth  ribs  in  about  the  mid-axillary  line.  Over  an  area 
here  measuring  about  5  inches  from  above  downwards  and  4 
inches  from  side  to  side  the  intercostal  spaces  were  indrawn 
and  felt  very  resistant.  There  was  absolute  dulness  on  per- 
cussion here,  except  just  at  the  edges  of  the  area,  where  it  was 
partial.  No  breath  sounds  were  audible  except  at  the  edge, 
where  they  could  be  faintly  distinguished,  and  slight  pleural 
friction  could  be  detected  here  and  there  on  deep  inspiration. 


Fig.  107  shows  a  photogra]Dh  of  the  patient  taken  before  the 
first  day  of  treatment. 

There  was  no  dulness  on  percussion  of  the  apices,  but  fine 
and  medium  crepitations  were  audible  at  both  apices  and  ante- 
riorly downwards  as  far  as  about  the  fourth  rib  on  either  side. 

The  rest  of  the  lungs  were  normal.  The  respiration  was  33 
per  minute. 

The  heart  was  displaced  to  the  right ;  the  apex  beat  could  be 
seen  and  felt  in  the  fourth  interspace  1  inch  to  the  right  of  the 
nipple  line ;  the  dulness  on  percussion  extended  to  1^  inches  to 


DISEASES   OF    THE   RESPIRATORY   ORGANS  331 

the  right  of  the  sternum.  The  heart  sounds  were  normal,  but 
the  cardiac  beat  was  accelerated  ;  the  pulse  rate  when  patient 
stood  up  was  116  per  minute. 

Patient's  appetite  was  poor.     He  had  a  motion  daily. 

Treatment. 

(I)  Heave  grasp  standing  chest  clapping,  side  shaking,  PP. 
{'2)  Loin  lean  stride  standing  alternate  rotation,  AE,  ringing, 

PP. 

(3)  Forwards  lying  back  exercise,  PP. 

(4)  Arch  forwards  lying  head  flexion,  PE,  extension,  AE. 

(5)  Stretch  stride  standing  bending  forwards,  PA,  given  with 
back  hacking,  PP. 

(6)  Half  lying  double  arm  rolling,  PP,  bending  and  stretching, 
AE. 

(7)  Left  hip  lean  walk  standing  lateral  flexion,  PE,  extension, 
AE. 

(B)  Eide  sitting  trunk  flexion,  PE,  extension,  AE, 

(9)  Half  lying  vibration  over  the  affected  pleura,  running 
intercostal  nerve  frictions,  side  shaking,  PP. 

(10)  Stretch  grasp  toe  standing  hanging,  breathing,  PA. 

(II)  Half  lying  stomach  exercise,  shaking  over  the  bladder, 
PP. 

(l'2i  Half  lying  trunk  stretching,  PA,  right  mid-dorsal  spinal 
muscle  frictions,  PP. 

Progress. — April  .5.  More  pain  than  usual  in  the  area  of 
dulness  in  the  left  side. 

April  10. — Pleural  friction  audible  all  over  the  area,  and  here 
and  there  for  about  2  inches  all  round  it. 

April  16. — Eespiration  easier.  Patient  said  that  he  felt  his 
back  to  be  straighter.     Appetite  normal  again. 

April  28. — All  the  crepitations  at  the  apices  disappeared. 
Patient  returned  to  work  again. 

May  4. — Pleural  friction  very  marked  in  the  whole  area  of 
dulness  in  the  left  side. 

August  1. — In  consequence  of  my  own  illness  (rheumatic 
fever  and  erythema)  I  did  not  again  examine  patient  until 
this  date.  During  my  inability  to  work,  however,  the  treatment 
was  applied  daily  by  Dr.  Harry  Kellgren  and  others.     The  area  of 


332     ELEMENTS   OF   KELLGREN'S   MANUAL    TREATMENT 

former  complete  dulness  was  now  only  partially  dull  on  per- 
cussion, and  was  also  smaller  in  extent,  measuring  about  2  inches 
by  8  inches.  Pleural  friction  was  audible  over  it,  and  in  a  few 
small  isolated  patches  round  it. 

September  27. — Treatment  finished.  Owing  to  my  temporary 
absence  I  did  not  examine  patient  until  October  5.  On  that  date 
he  still  suffered  some  pain  in  the  left  side,  but  it  was  never 
sharp  and  stabbing  as  it  used  to  be.  The  spinal  column 
was  straighter.  The  point  of  greatest  convexity  was  distant 
4  c.  from  a  line  drawn  between  the  spines  of  the  first  dorsal 
and  first  lumbar  vertebrfe.     On    attempting    to    straighten    the 


spine  this  distance  could  be  reduced  to  3  c.  The  left  side  was 
much  less  sunken  in  (see  fig.  108).  There  was  no  dulness  on 
percussion ;  pleural  fi-iction  was  audible  over  the  area  of  former 
dullness  and  in  the  fifth  and  sixth  interspaces  for  about  2  inches 
in  their  length  outside  the  apex  beat.  The  respiration  was  19 
per  minute. 

The   apex   beat    could   be   seen  and   felt   in   the  fourth    and 
fifth  interspaces,  about  half  an  inch  internal  to  the  nipple  line. 


DISEASES   OF    THE   RESPIRATORY   ORGANS  333 

The  pulse  on  standing  up  was  7'2  per  minute.  Appetite  was 
good.     General  condition  was  stronger. 

Although  this  case  was  by  no  means  cured,  it  shows  what 
could  be  effected  even  when  the  abnormal  condition  had  lasted  for 
more  than  five  years  before  coming  under  the  influence  of  the 
manual  treatment. 

It  may  not  be  out  of  place  here  to  make  some  remarks  on  the 
treatment  of  spinal  curvatures  by  means  of  combining  gymnastic 
methods  with  mechanical  support  from  a  corset,  Sec.  I  heartily 
agree  with  the  doctrine  of  the  Ling  school,^  which  has  always 
been  that  such  mechanical  appliances,  by  giving  support  to  the 
weakened  muscles  and  thereby  partially  rendering  their  co- 
operation unnecessary,  do  more  harm  than  good.  The  principle 
of  their  action  is,  in  fact,  directly  opposed  to  the  principle  of 
gymnastic  treatment,  the  object  of  the  latter  being  invariably 
to  strengthen  the  weakened  muscles  at  the  expense  of  their 
antagonists. 

Wide,^  however,  recommends  the  use  of  such  mechanical 
appliances. 


^  See,  for  example,  Hartelius,  "Larobok  i  Sjukgymnastik,"  1883,  pp.  326,327; 
1892,  pp.  314,  315;  and  "  Skolios  och  dess  Behandling  med  Sjukgymnastik,"  in 
Tidskrift  i  Gymnastik,  1881,  part  15,  pp.  913,  914. 

-  "  Handbok  i  Mediciusk  Gymnastik,"  1896,  pp.  429,  &e.  ;  "  Handbook  of  Medical 
Gymnastics,"  1899,  pp.  358,  &c. ;  "  Handbok  i  Medicinsk  och  Ortopedisk  Gym- 
nastik," 1902,  pp.  363,  &c. ;  "  Handbook  of  Medical  and  Orthopaedic  Gymnastics," 
1903,  p.  357. 


CHAPTER    V. 

DISEASES    OF    THE    DIGESTIVE    ORGANS. 

Acute  Membranous  Tonsillitis. 

K.  I.,  male,  aged  45,  already  under  treatment  for  lateral 
sclerosis,  came  to  my  house  for  his  usual  daily  treatment  on 
October  16,  1899.  During  the  evening  of  the  same  day  patient 
felt  feverish  and  had  some  difliculty  in  swallowing. 

October  17. — Aggravation  of  these  symptoms  ;  during  the 
course  of  the  afternoon,  delirium,  lasting  for  about  an  hour, 
supervened  at  4  p.m.     I  saw  patient  at  7  p.m. 

Examination. — Patient  fairly  clear  in  his  head  ;  difliculty  in 
swallowing ;  both  tonsils  enlarged  and  swollen,  and  patches  of 
yellowish  membrane  on  them;  uvula  also  swollen,  but  no  mem- 
brane on  either  it  or  the  pillars  of  the  fauces.  Fever  and  accel- 
erated pulse  rate  ;  after  treatment,  temperature  104°,  pulse  130. 

October  18. — Treatment  twice.  During  morning,  temperature 
102"6°,  pulse  125 ;  after  treatment,  102'  and  115  respectively. 
During  the  evening,  temperature  and  pulse  100"2°  and  108,  and 
996°  and  106  respectively  before  and  after  treatment. 

October  19. — Morning.  Swallowing  easier.  Temperature 
100"4°,  pulse  112.  Treatment,  after  which  temperature  99"8°, 
pulse  102. 

Evening.  Temperature  99"2°,  pulse  98.  Treatment,  after 
which  temperature  98'6°,  pulse  96. 

October  20. — Patient  got  up  and  walked  about.  Swallowing 
much  easier  ;  no  membrane  left,  only  some  redness.  Treatment 
once  during  the  evening.     Temperature  97'8°,  pulse  65. 

October  21. — No  redness.  Temperature  98'6°,  pulse  70. 
Treatment  once. 

October  22. — Patient  went  out  for  a  walk. 

October  23. — Treatment  stopped  as  regards  the  throat  afl'ec- 
tion,  the  throat  being  normal. 


DISEASES   OF    THE   DIGESTIVE   ORGANS  335 

December  10. — Throat  had  remained  quite  well  since  I  had 
last  seen  it. 


Treatment. 

Vibrations  on  the  larynx,  pharj'nx  and  sublingual  regions ; 
frictions  on  the  nerves  of  these  parts.  General  treatment  for 
fever. 

Acute  Catarrhal  Appendicitis. 

To  Henrik  Kellgren  belongs  the  credit  of  having  been  the 
first  to  introduce  gymnastic  methods  into  the  treatment  of  acute 
appendicitis.  A.  Levin  of  the  G.  C.  I.  made  efforts  in  this 
direction,  the  incentive  being,  as  be  himself  says,  what  he  saw 
while  studying  under  Henrik  Kellgren  during  1887  ;  his  results 
were  published  in  1892\  Hartelius  does  not  mention  appendicitis 
in  his  handbook.^  Wide,  of  course,  strongly  condemns  all  attempts 
at  gymnastic  methods  for  appendicitis. ■' 

The  objects  of  Kellgren's  treatment  as  applied  to  acute 
appendicitis  are  as  follows  : — 

(1)  To  diminish  the  inflammatory  process  in  the  appendix, 
and  thereby  prevent  the  formation  of  abscess  ;  and  to  diminish 
the  tendency  to  the  formation  of  adhesions,  exudation,  &c.,  round 
about  the  local  lesion,  or  if  such  have  formed,  to  remove  them. 

(2)  To  diminish  the  tension  in  the  abdomen,  and  thereby  cause 
the  blood  and  lymph  flow  to  proceed  better ;  and  to  prevent  stasis, 
which  so  powerfully  predisposes  to  lowered  vitality  of  the  part. 

(3)  To  improve  the  constitution  generally. 

These  objects  are  gained  by  means  of  the  following  manipula- 
tions : — 

(a)  Vibrations  over  the  appendix  and  over  any  inflamed  or 
painful  area  in  the  right  iliac  fossa. 

(6)  Gentle  stomach  exercise  administered  at  first  only  on  the 
left  half  of  the  abdomen  ;  making  the  patient  practise  deep  respira- 

'  "  Om  Massage  vid  BliudtarmsinflammatioD,"  iu  Tidskrift  i  Gymnastik,  1892, 
pp.  684,  &o. 

-■  "  Larobok  i  Sjukgymnastik,"  1870,  1883,  1892. 

»  "  Handbok  i  Medicinsk  Gymnastik,"  1896,  p.  226;  "  Haudbook  of  Jledical 
Gymnastics,"  1899,  p.  209;  "  Handbok  i  Medicinsk  och  Ortopedislc  Gymnastik," 
1902,  p.  201  ;  "  Handbook  of  Medical  and  Ortbopa?dic  Gymnastics,"  1903,  p.  214. 


336     ELEMENTS   OF  KELLGREN'S   MANUAL    TREATMENT 

tions,  side  shaking,  vibrations  or  frictions  on  the  lower  intercostal 
nerves  (thereby  also  affecting  the  splanchuics),  &c. 
(c)  General  treatment  for  fever. 

Case  1. 

Mr.  K.,  aged  43,  came  under  the  manual  treatment  on 
August  18,  1898. 

Previous  history. — Quite  good. 

History  of  present  illness. — Patient  was  seized  on  August  17, 
1898,  throughout  the  abdomen  generally  with  sudden  pains, 
which  did  not  seem  to  arise  from  any  particular  spot ;  he  could 
assign  no  cause  for  their  coming  on.  In  a  quarter  of  an  hour  or 
so  he  felt  very  bad  and  went  to  bed.  Fever  set  in  some  two  or 
three  hours  later,  and  patient  was  then  able  to  locate  the  pains 
in  his  right  iliac  fossa.  He  felt  very  weak  and  ill,  and  during  the 
evening  of  the  same  day  sent  for  his  medical  man.  The  latter 
diagnosed  appendicitis,  and,  while  making  his  examination,  he 
palpated  the  right  iliac  region,  which  caused  the  patient  ver}' 
much  pain.  An  ice-bag  was  placed  on  the  right  iliac  region,  an 
enema  given,  and  opmm  prescribed.  There  had  been  no  motion 
since  the  morning  of  August  16  ;  the  enema  did  not  call  forth  one. 

Patient  slept  very  badly  ;  the  pains  in  the  abdomen  increased, 
and  nausea  set  in,  although  no  actual  vomiting  occurred.  No 
motion  took  place,  and  the  appetite  disappeared.  On  August  18 
the  medical  man  said  that  if  the  temperature  rose  any  more  he 
must  operate.  Patient  did  not  like  the  idea  of  an  operation,  and 
thought  he  would  instead  try  the  manual  treatment.  I  was  called 
in  during  the  evening  of  August  18. 

Examination. — Patient  in  bed,  with  sunken  eyes,  looking  very 
weak.  He  preferred  lying  on  his  back  with  his  legs  drawn  up. 
He  complained  of  continued  severe  pain  in  the  right  iliac  region, 
and  a  sense  of  weight  and  oppression  in  the  abdomen  generally ; 
also  of  headache  and  general  weakness.  A  sense  of  nausea  was 
present,  but  no  actual  vomiting  had  occurred  ;  sometimes  eructa- 
tions and  also  passage  of  flatus  per  rectum  took  place.  Patient 
had  eaten  nothing  all  day,  but  had  drunk  some  water  at  intervals. 
No  motion  had  taken  place  since  the  morning  of  the  16th. 

The  abdomen  looked  distended ;  it  was  very  resistant  on 
palpation,  especially  in  the  region  of  the  right  iliac  fossa,  where 


DISEASES    OF     THE    DIGESTIVE    ORGANS  337 

even  slight  pressure  caused  a  good  deal  of  acute  pain,  the  pain 
being  most  marked  at  McBurney's  point.  There  was  reflex  eon- 
traction  of  the  abdominal  muscles  over  the  right  half  of  the 
abdomen,  and  the  abdomen  did  not  move  with  respiration.  The 
urine  was  dark  and  scanty.  No  rigors  had  occurred.  No  rectal 
examination  was  made.     Temperature  102'4' ;  pulse  115,  weak. 

Treatment. 

Vibrations  over  the  painful  part,  especially  the  point  of 
greatest  pain,  which,  however,  often  changed  its  place,  the  point 
of  application  of  the  vibrations  being  changed  accordingly.  In 
the  course  of  a  few  minutes  the  pain  diminished,  and  the  patient 
could  stretch  out  his  legs  without  extra  pain.  After  a  few  more 
minutes  the  contraction  in  the  abdominal  muscles  grew  less,  and 
the  vibrations  could  be  administered  with  greater  vigour.  In 
addition,  gentle  stomach  exercise,  side  shaking,  kc,  head 
vibration,  and  the  ordinary  treatment  for  fever. 

After  the  treatment  patient  looked  and  felt  better.  The  head- 
ache had  been  perceptibly  lessened.  The  abdomen  was  less 
distended,  this  being  partially  due  to  the  patient  having  vented 
much  gas  from  his  stojiiach  and  passed  a  good  deal  of  flatus  per 
rectum  ;  but  no  motion  had  resulted.  There  was  less  contraction 
in  the  abdominal  muscles,  especially  over  the  right  iliac  fossa,  and 
much  less  pain  in  that  region,  where  a  circumscribed  tumour 
could  be  made  out,  although  the  boundaries  could  not  be  well 
defined  on  account  of  the  tenderness.  Temperature  100'2° ; 
pulse  93. 

Patient  remained  fairly  comfortable  until  about  two  hours 
after  the  treatment,  when  the  pain  in  the  right  iliac  fossa  set  in 
again.     He  slept  fairly  well. 

August  19. — 9  a.m.  No  motion  yet.  Patient  had  suffered  a 
good  deal  of  pain  in  the  right  iliac  fossa  ;  it  was,  however,  not  so 
bad  as  when  I  first  saw  him,  and  he  had  been  able  to  lie  with  his 
legs  straight  all  night.  The  tumour  was  considerably  smaller 
than  during  the  previous  evening.  Temperature  100° ;  pulse  100. 
Treatment  as  before. 

3  p.m.     Temperature  102° ;  pulse  100.     Treatment. 

9  p.m.  The  tumour  has  been  reduced  to  a  small  round  mass. 
The  urine  was  clearer,  the  quantity  greater  than  during  the 
22 


338     ELEMENTS   OF   KELLGREN'S    MANUAL   TREATMENT 

previous  day.  Teinperatiue  101  9"  ;  pulse  lOG.  Patient  had 
consumed  notliing  during  the  day  except  a  little  milk.  Treatment. 
Patient  was  treated  three  times  during  the  course  of  this  day, 
and  each  time  the  treatment  almost  entirely  removed  the  pain  in 
the  right  iliac  fossa,  it  being  then  only  perceptible  on  considerable 
pressure. 

August  20. — Patient  slept  very  well.  During  the  early 
morning  he  passed  a  copious,  evil-smelling  black  motion. 

10  a.m.  Not  much  pain  in  the  right  iliac  fossa.  Temperature 
99'8°,  pulse  103.  Treatment  as  before  ;  after  it  no  pain  on  deep 
pressure  in  the  right  iliac  fossa,  only  some  tenderness.  Sense  of 
resistance  was  still  present,  but  no  tumour  could  be  felt.  After 
treatment  patient  got  up  and  sat  up  in  a  chair  ;  he  ate  some 
bread  and  butter  and  drank  some  milk  during  the  course  of  the 
day. 

Evening.  Temperature  101'5°,  pulse  108.  Blight  return  of 
the  pain,  which,  however,  disappeared  after  the  treatment.  The 
urine  was  still  clearer.      Another  motion  during  the  evening. 

August  21. — Patient  up  all  day.  Appetite  returning;  one 
motion.  No  sense  of  resistance  in  the  right  iliac  region.  Tem- 
perature  99°,  pulse  90.     Treatment  once  during  the  evening. 

August  22. — Patient  feeling  normal,  except  for  weakness  ;  he 
walked  from  his  house  to  Sanna  (distance  three-quarters  of  a 
mile),  and  in  addition  to  vibrations,  &c.,  over  the  abdomen,  and 
stomach  exercise,  performed  some  active  exercises.  No  tender- 
ness any  more  in  the  abdomen.  Urine  normal.  One  motion 
during  the  course  of  the  day. 

August  23. — Patient  had  eaten  daring  the  previous  day  as 
usual,  meat,  vegetables,  milk,  &c.  He  did  not,  however,  feel 
equal  to  walking  to  Sanna,  and  so  was  treated  at  home.  Tem- 
perature 98°,  pulse  8.5. 

August  24. — Patient  drove  to  Sauna,  where  he  was  treated. 

August  25  to  September  5. — Patient  walked  to  Sanna  and 
back  daily.  He  received  special  treatment  for  the  abdomen  and 
a  few  active  strengthening  movements.  Motion  daily  since 
August  22. 

September  5. — Treatment  finished.     Patient  normal. 

Patient-,  who  had  enjoyed  excellent  health  ever  since  his 
illness,  emigrated  to  America  in  February,  1901 ;  I  have  not 
heard  of  him  since. 


DISEASES    OF    THE   DIGESTIVE   ORGANS  339 

Case  2. 

J.  A.  S.,  aged  35,  male,  came  under  the  manual  treatment 
on  July  23,  1902. 

Previous  history. — Patient  had  always  been  well  and  strong. 

History  of  present  illness. — On  getting  up  at  6  a.m.  on 
July  22  he  felt  ill,  but  went  to  work  as  usual.  The  feeling  of 
illness  increased,  and  he  was  obliged  to  go  home ;  at  about 
9  a.m.  he  was  seized  with  pains  in  the  arms  and  abdomen,  and 
had  to  go  to  bed.  He  vomited  watery  stuff  all  the  morning,  and 
perspu-ed  very  much.  Towards  afternoon  the  abdominal  pain 
became  more  severe  ;  he  was  unable  to  assign  its  origin  to  any 
particular  spot.  At  about  4.30  p.m.  he  had  rigors,  which  lasted 
until  6  p.m.,  and  the  pain  in  the  abdomen,  which  he  could  now 
locate  in  the  right  iliac  fossa,  became  so  severe  that  he  screamed 
continually.  He  lay  on  his  back  with  his  legs  drawn  up, 
occasionally,  however,  rolling  about  in  bed  for  sheer  pain.  At 
about  7  p.m.  he  was  relieved  somewhat  by  a  motion  which  looked 
normal,  although  it  smelt  worse  than  usual.  He  did  not  sleep 
at  all  because  of  the  pain,  and  at  about  4  a.m.  the  following 
morning  (July  23)  had  another  rigor,  this  time  of  an  hour's 
duration.     At  10  a.m.  I  was  sent  for. 

Examination. — Patient  was  lying  on  his  back,  with  flushed 
face  ;  there  was  no  abdominal  look.  He  preferred  lying  with  his 
legs  drawn  up,  especially  the  right  one,  but  was  able  to  lie  with 
them  straightened.  He  complamed  of  severe  pain  in  the  region 
of  the  right  iliac  fossa,  and  also  to  a  less  extent  in  the  whole 
right  half  of  the  abdomen.  There  was  contraction  of  the 
abdominal  muscles  of  the  right  half  of  the  abdomen  ;  tenderness 
on  palpation,  and  great  tenderness  to  pressure  in  the  right  iliac 
fossa ;  cutaneous  hyperaesthesia  at  McBurney's  point.  The 
whole  right  half  of  the  abdomen  was  filled  up  by  a  large  tender 
mass  which  was  fairly  hard,  especially  in  the  right  iliac  fossa. 
The  left  side  of  the  abdomen  was  normal.  The  spleen  and  sixth 
to  twelfth  dorsal  nerves  of  the  right  side  were  tender  to 
friction.  The  urine  was  darker  than  normal.  Temperature  101'3° 
(all  the  temperatures  were  taken  jjer  rectum),  pulse  102,  thready. 

After  treatment  there  was  no  pain  and  very  little  tenderness, 
although  the  contraction  of  the  abdominal  muscles  was  only 
slightly  improved.  Patient  looked  better  and  said  that  he  felt 
better.    He  drank  some  soup.    Treatment  twice  a  day  henceforth. 


340      ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

Evening.  The  pain  and  tenderness  had  returned  to  some 
extent,  and  the  abdominal  muscles  were  more  firmly  contracted. 
Temperature  101 'S",  pulse  90.  No  pain  after  treatment,  and  very 
little  tenderness.  Patient  drank  some  more  soup  and  went 
to  sleep. 

July  24. — Morning.  Patient  had  slept  fairly  well ;  and  eaten 
an  egg  for  breakfast.  Right  iliac  fossa  very  tender.  Temperature 
101'8°,  pulse  76.     Urine  normal. 

Evening.  Patient  had  at  intervals  been  sitting  up  in  bed,  and 
had  left  it  altogether  while  it  was  being  remade.  He  ate  an  egg 
and  some  bread  and  butter  during  the  evening.  No  motion. 
Temperature  100"6°,  pulse  72.  After  treatment  no  pain  and  not 
much  tenderness. 

July  2.5. — Patient  slept  well,  and  ate  an  egg  and  bread  and 
butter,  and  drank  some  milk  for  breakfast. 

Morning.  No  pain  at  all ;  tenderness  in  abdomen  about  the 
same  as  during  the  previous  evening.    Temperature  99'9°,  pulse  65. 

Patient  got  up  for  a  few  minutes  during  the  course  of  the  day. 
He  ate  pancakes  with  cranberries  and  milk  for  dinner.  Later, 
after  fifteen  minutes  effort,  he  passed  a  motion  consisting  of  a 
few  very  hard  lumps. 

Evening.  At  supper,  patient  took  the  same  food  as  at  break- 
fast.    Temperature  101.1°,  pulse  72. 

July  26. — Patient  slept  well ;  he  ate  during  the  day  about  the 
same  as  during  the  previous  day.     No  motion  took  place. 

Morning.  Temperature  101"1°,  pulse  68.  During  the  course  of 
the  day  there  was  some  return  of  the  pain,  and  the  tenderness 
was  more  marked. 

Evening.    Condition  improved.    Temperature  101'.5°,  pulse  72. 

July  27. — For  breakfast  patient  ate  an  egg,  some  cold  meat 
and  some  bread  and  butter,  and  drank  some  milk. 

Morning.  Patient  much  better.  Only  slight  tenderness  left 
in  right  iliac  fossa,  none  in  the  rest  of  the  right  side  of  the 
abdomen.  The  large  mass  in  the  right  iliac  fossa  much  smaller, 
only  about  the  size  of  a  billiard  ball.  Hardly  any  contraction  of 
the  abdominal  muscles.     Temperature  99'9°  pulse  .54. 

Evening.  Patient  had  a  motion  during  the  afternoon  which 
was  rather  hard,  though  otherwise  normal,  and  was  up  for  an 
hour.  He  had  milk  and  bread  and  butter  both  for  dinner  and 
supper.     Temperature  99°,  pulse  60. 


DISEASES   OF    THE   DIGESTIVE   ORGANS  34i 

July  28. — Treatment  only  once  a  day  henceforth,  during  the 
morning. 

Morning.  Patient  much  hetter ;  the  mass  in  the  right  iliac 
fossa  rapidly  disappearing.  Temperature  98"1°,  pulse  54.  Diet : 
breakfast,  egg,  milk  and  bread  and  butter  ;  dinner,  meat,  potatoes 
and  milk ;  supper,  porridge  and  milk.  Patient  was  up  all  the 
afternoon.     No  motion. 

July  29. — Morning.  Temperature  97'9°,  pulse  .56.  Patient 
up  all  day.     Motion. 

July  80. — Slight  tenderness  in  the  right  iliac  fossa,  otherwise 
nothing  abnormal  in  the  abdomen.  Patient  went  out  for  a  walk  ; 
he  would  have  done  so  the  previous  day  had  it  not  rained  without 
ceasing.     No  motion. 

July  31. — Patient  stronger.     Motion. 

August  1. — Patient  walked  to  my  villa  and  back  for  treat- 
ment (distance  nearly  one  mile  each  way). 

August  3. — No  treatment. 

August  9. — Motion  daily  since  August  1.  Treatment  finished. 
There  had  been  no  tenderness  in  the  abdomen  since  the  5th,  but 
patient  had  continued  treatment  in  order  to  regain  his  strength. 

August  11. — Patient  returned  to  the  factory,  working  as  usual 
for  nine  and  a  half  hours  a  day. 

September  18,  1902. — Patient  had  been  quite  well  ever  since 
his  illness. 

The  treatment  was  practically  the  same  as  for  the  last  case. 

Acute  Rapidly  Extending  Peritonitis. 

Mrs.  S.,  aged  39,  came  under  the  manual  treatment  on  Feb- 
ruary 25,  1902. 

Previous  historij. — Patient  had  suffered  from  chronic  constipa- 
tion for  the  last  twelve  or  fifteen  years.  She  had  had  nine  chil- 
dren. On  February  8  she  was  delivered  of  her  ninth  child,  the 
labour  being  normal  in  every  respect. 

Historij  of  present  illness. — On  February  24  she  went  out  for 
the  first  time  since  her  confinement  in  order  to  go  to  the  closet, 
which  was  in  an  outhouse  (as  is  usual  in  the  country  in  Sweden). 
She  had  not  had  a  proper  motion  since  her  confinement ;  this 
time,  as  usual,  she  had  to  wait  some  minutes  before  the  motion 
came.    It  was  very  cold  ( —  8°  C.)  and  windy,  and  she  felt  that  she 


342     ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

got  a  chill.  During  the  evening  of  the  same  day  she  had  a  rigor 
lasting  about  five  minutes,  followed  by  attacks  of  sharp  stabbing 
pains  in  the  whole  of  the  abdomen ;  these  recurred  at  ever  shorter 
intervals.  The  midwife  who  attended  her  last  confinement  was 
called  in,  and  administered  an  enema  which  resulted  in  a  motion. 
During  the  night  patient  was  feverish,  felt  very  ill  and  had 
continued  attacks  of  violent  pain  in  the  abdomen,  which  were 
so  bad  as  to  cause  her  to  cry  out.  Slight  relief  was  obtained  by 
keeping  her  legs  drawn  up.  The  attacks  lasted  from  ten  to 
fifteen  minutes,  and  the  pauses  between  them  lasted  from  two  to 
three  minutes  only.  She  was  quite  unable  to  move  without 
bringing  on  the  attacks.     On  one  occasion  she  vomited. 


FEB. 

MARCH 

DATE 

25       1          26 

27     128 

1 

2 

3 

4 

5 

6 

7 

TIME 

^°M^^ 

^W 

AM   PM    "^  ^ 

M  t 

M  E 

M  E 

M  E 

M  E 

M  E 

M 

F° 

103" 
102" 
lOl" 
100 " 
30" 
9S' 
97" 
96' 

Mouth 

^/" 

V 

V  . 

^ 

^  A 

'    \ 

y 

' 

I 

r^ 

\ 

J 

/ 

PULSE 

IIZ     100 
106    100 

00     84     68 
67      80 

62 
68     68 

80 
84 

%> 

84 
82 

84 
73 

78 
66 

76 
73 

74 
68 

72 

Examination. — February  25.  Morning,  9  a.m.  Patient 
lying  on  her  back  with  her  legs  drawn  up,  abdominal  facies  very 
marked.  Complained  of  attacks  of  pain  in  the  abdomen,  chiefly 
the  lower  part,  the  pain  being  so  intense  as  to  cause  her  to 
cry  out,  and  being  aggravated  by  the  slightest  movement. 
Eeflex  contraction  of  abdominal  muscles  present,  especially  in 
the  hypogastric  region.  Respiration  accelerated  and  purely 
thoracic,  abdominal  breathing  impossible.  Patient  could  hardly 
bear  the  slightest  touch  on  her  abdomen.  Great  tenderness  over 
sixth  to  eleventh  dorsal  nerves  near  the  spine.  Vaginal  discharge 
increased  in  amount,  no  bad  odour.  Micturition  caused  a  burn- 
ing sensation  and  much  pain.  Thready  pulse.  (For  temperature 
and  pulse  see  separate  chart,  fig.  109.) 


DISEASES   OF    THE    DIGESTIVE   ORGANS  343 

1  first  executed  very  fine  vibrations  over  the  hypogastric 
region,  gradually  increasing  their  strength,  and  maintained  these 
for  three-quarters  of  an  hour.  During  that  time  patient  suffered 
only  three  attacks  of  pam,  which  were  less  severe  than  those 
occurring  during  the  night  and  only  lasted  from  two  to  five 
seconds,  and  the  abdomen  became  less  tender.  I  then  executed 
vibrations  over  the  abdomen  as  a  whole  and  frictions  on  the 
ovaries  and  the  dorsal  and  lumbar  spinal  nerves.  I  tried  to 
get  patient  to  breathe  abdominally,  but  the  attempt  was  attended 
with  too  great  pain  ;  some  eructation  followed. 

11.30  a.m.  Pains  less  severe  than  during  the  night,  but 
now  experienced  all  over  the  abdomen.  Tenderness  in  entire 
abdomen,  especially  in  epigastrium.     A  good  deal  of  eructations. 

2  p.m.  Patient  had  vomited  twice  since  11.30.  Large 
amount  of  eructations.  After  treatment  abdomen  softer,  and 
able  to  bear  more  pressure  than  before  ;  patient  able  to  move  in 
bed  without  pain  ;  abdominal  respiration  fairly  easy  and  attended 
by  little  pain. 

5  p.m.  Patient  had  vomited  once  since  last  treatment.  Pain 
less,  chiefly  in  epigastrium.  Fever  less.  Treatment,  after  which 
patient  slept  for  three  hours. 

11  p.m.  There  had  been  no  vomiting  since  the  afternoon. 
Patient  better.     Treatment. 

February  26. — 5  a.m.  Eather  severe  pain  from  2  to  4  a.m.  ; 
since  then  less  severe     Treatment. 

9  a.m.     Treatment  repeated. 

2  p.m.  Abdomen  moved  unconsciously  during  respiration ; 
deep  abdominal  respiration  only  caused  uneasiness.  Pain  much 
less  severe.  Fairly  strong  pressure  could  be  applied  to  the 
abdomen,  and  a  gentle  stomach  exercise  was  administered  ; 
gurgling  sounds  from  the  intestines  could  be  heard  meanwhile. 
Patient  passed  flatus  several  times  during  the  morning. 

8  p.m.  Patient  had  slept  ever  since  I  treated  her  last.  Patient 
drank  some  soup  during  the  afternoon.     Treatment. 

11  p.m.  Not  much  pain  ;  vomiting  entirely  ceased  since  the 
previous  day.     Treatment. 

February  27. — 9  a.m.  Patient  had  been  sitting  up  in  bed  for 
two  hours  before  my  arrival,  with  hardly  any  pain.  After  treat- 
ment she  got  up  and  sat  on  the  sofa  while  the  bed  was  being 
made.     Very  little  pain. 


344     ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

3  p.m.     Treatment. 

8  p.m.  Patient  had  been  drinking  milk  and  soup.  I  adminis- 
tered, among  other  manipulations,  an  ordinary  stomach  exercise. 
Hardly  any  pain. 

Patient  treated  twice  a  day  henceforth. 

February  28. — 9  a.m.  Patient  had  passed  two  motions  dur- 
ing the  night ;  they  were  black  and  smelt  very  badly.  After  the 
first  she  had  had  some  pain,  but  after  the  second  none.  She  had 
eaten  some  bread  and  butter  and  drunk  some  milk.  She  began 
this  morning  to  give  her  baby  milk  from  the  breast  for  the  first 
time  since  her  illness  (I  did  not  know  of  this  until  several  days 
afterwards),  and  during  the  afternoon  she  sat  on  the  sofa  for  two 
hours. 

7  p.m.  One  tender  spot  in  the  right  iHac  fossa.  A  medium 
vibration  executed  on  it  for  a  few  seconds  caused  a  loud  gurgling 
sound,  followed  by  immediate  cessation  of  the  tenderness. 

March  1. — One  motion.  The  tender  spot  in  the  right  iliac 
fossa  had  returned,  and  there  was  still  some  tenderness  over  the 
lower  dorsal  nerves;  distinct  improvement  in  both  after  treat- 
ment.    Patient  up  during  most  of  the  day. 

March  2. — A  motion  during  the  night  ;  for  a  while  after  it 
some  pain,  which  then  ceased  permanently.  The  tenderness  in 
the  right  iliac  fossa  had  disappeared.  Patient  ate  meat,  eggs, 
milk,  &c.,  and  was  up  all  day. 

March  3. — One  motion.  Patient  ate  her  ordinary  food  and 
was  up  all  day.  During  the  evening  she  said  that  beyond  a 
feeling  of  looseness  and  tiredness  in  the  abdomen,  and  some 
weakness  in  general,  she  felt  quite  normal. 

March  .5  to  10. — Motion  daily.  Active  exercises  prescribed, 
amongst  others,  sitting  trunk  extension  and  flexion,  PA.  On 
March  10  patient  went  out  for  a  few  minutes ;  the  temperature 
was  —  7°  C. 

March  13. — Some  weakness  still  left.  Patient  was  fulfilling 
her  household  duties  as  usual.    Treatment  once  a  day  henceforth. 

March  22.  — Motion  daily ;  patient  normal.  Treatment  finished. 

July  12,  1902. — Patient  had  had  a  motion  daily  since  above 
date.  She  said  that  she  felt  stronger  than  before  her  illness,  that 
her  digestion  had  also  been  better,  e.g.,  she  had  been  able  to  eat 
freely  of  fatty  articles  of  diet,  which  before  her  illness  she  had 
never  been  able  to  do. 

August,  1903. — Still  keeping  quite  well. 


DISEASES    OF   THE  DIGESTIVE   ORGANS  345 

Acute  Gastro-Intestinal  Catarrh. 

Hartelius'  states  that  acute  gastric  catarrh,  when  severe  and 
combined  with  fever,  is  not  amenable  to  gymnastic  treatment. 

Miss  L.,  aged  13,  came  under  the  manual  treatment  on 
December  19,  1900. 

Previous  history. — Good. 

History  of  present  illness. — Patient  was  taken  ill  on  December 
17,  1900 ;  the  onset  was  sudden,  and  accompanied  by  a  rigor, 
fever,  and  severe  headache.  About  an  hour  afterwards  patient 
vomited  some  green  matter,  repeating  this  at  intervals.  Greenish 
diarrhoea  appeared  during  the  course  of  the  day,  the  colour  chang- 
ing to  brown  after  a  few  motions.  Patient  slept  very  badly, 
vomited  every  half  hour,  and  was  delirious.  December  18. — 
Patient  vomited  about  once  an  hour  during  the  day,  the  vomit 
being  still  greenish  in  colour,  and  she  suffered  from  continued 
diarrhoea  and  high  fever.  She  was  again  delirious  during  the 
night. 

On  the  morning  of  December  19  I  was  sent  for. 

Examination. — Patient  had  been  vomiting  green  matter  all 
night  at  intervals  of  about  an  hour,  and  had  had  two  diarrhoeic 
motions  to-day.  She  had  been  delirious  all  night,  and  was  so 
when  I  saw  her  ;  on  being  asked  questions  she  invariably  replied : 
"  I  have  a  very  bad  headache."  She  had  eaten  nothing  since 
December  17,  and  had  only  drunk  water,  which  was  invariably 
vomited  after  a  few  minutes.  Temperati;re  104° ;  pulse  138. 
The  breathing  was  thoracic  and  laboured,  the  abdomen  painful 
and  tender,  and  in  it  continued  gurgling  sounds  were  audible, 
which  were  greatly  increased  on  slight  pressure.  The  heart  and 
lungs  showed  nothing  abnormal. 

The  vomit  had  been  thrown  away,  and  I  was  therefore  unable 
to  see  a  specimen. 

Treatment. — Head  exercise,  abdomen  vibrations ;  after  a  few 
minutes  I  could  administer  a  gentle  stomach  exercise.  I  also 
executed  spinal  nerve,  kidney  and  spleen  frictions,  &c.  After 
treatment  patient  became  clear  in  her  head,  and  was  able  to 
sit  up.  The  abdominal  pain  was  diminished,  the  headache  alle- 
viated, and  the  general  appearance  improved. 

'"Om  SjukgymnastikenvidGymnastiska Central  Institutet  under ar  1863,"  1864, 
p.  48. 


346      ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

6  p.m.  same  day.  There  bad  been  no  diarrhoea  or  vomiting 
since  my  last  visit.  Tenderness  in  abdomen  ahuost  gone ;  very 
little  headache.  Temperature  99'2°,  pulse  102.  Treatment 
as  before. 

December  20. — Patient  had  slept  very  well,  and  appetite  was 
returning.  No  vomiting  since  the  previous  evening ;  one  soft 
motion.  Temperature  and  pulse  normal.  Patient  got  up  and  sat 
in  a  chair  during  the  greater  part  of  the  day.     Treatment  once. 

December  21. — Beyond  a  general  feeling  of  weakness,  patient 
felt  quite  well.     Treatment  for  the  last  time. 

August  2,  1902. — No  return  of  the  symptoms. 

Acute  Intestinal  Catarrh.' 

Mrs.  S.,  wife  of  my  coachman,  aged  2S,  came  under  the 
manual  treatment  on  August  20,  1900. 

Previous  liistory. — Patient  had  had  incipient  phthisis  seven 
years  previously,  which  was  cured  by  the  manual  treatment. 
Since  then  she  had  been  fairly  strong. 

History  of  present  illness. — On  August  19,  1900,  patient  was 
employed  during  the  greater  part  of  the  day  in  washing  clothes, 
and  getting  tired  she  laid  down  in  the  damp  grass  to  rest.  During 
the  evening  she  walked  to  a  neighbouring  town  three  miles  off. 
She  slept  fairly  well  until  8.30  a.m.,  when  she  was  conscious  of 
severe  headache,  shivering  attacks,  and  pain  in  the  abdomen ; 
profuse  and  frequent  diarrhoea  came  on,  greenish  in  colour.  I  was 
sent  for  at  11  a.m. 

Examination.  —  Patient  did  not  recognise  me,  and  when  I 
asked  her  questions,  kept  on  saying  that  she  had  a  headache. 
She  perspired  freely,  and  her  head  felt  very  hot.  Temperature  not 
taken  as  I  had  no  thermometer  with  me ;  pulse  140.  Abdomen 
painful  and  gurgling  and  tender  to  touch. 

Treatment. — Vibrations  over  the  abdomen  ;  head  exercise, 
spinal  nerve  frictions,  kidney  and  spleen   frictions.      In  conse- 

'  See  Wide,  "Handbook  of  Medical  and  Orthopsedic  Gymnastics,"  1903,  pp. 
209,  210:  "Intestinal  catarrh,  both  acute  and  chronic  is  treated  by  Swedish 
gymnasts  with  abdominal  movements.  In  acute  intestinal  catarrh  this  treatment 
should  he  advised  against  by  everyone  who  knows  that  rest  for  the  whole  constitution 
and  intestines,  produced  by  suitable  means,  is  effective  within  a  few  hours."  Set' 
also  "  Handbok  i  Jledicinsk  Gymnastik,"  1896,  p.  219;  "Handbook  of  Medical 
Gymnastics,"  1899,  p.  204;  "Handbok  i  Medicinsk  och  Ortopedisk  Gymnastik," 
1902,  p.  20i. 


DISEASES  OF    THE    DIGESTIVE   ORGANS  347 

quence  the  abdomen  became  less  tender,  and  patient  recognised 
me  again.     Pulse  110  after  treatment. 

4  p.m.  Temperature  104°,  pulse  108.  Patient  again  wander- 
ing in  her  mind.  Dia^rrhoea  now  greenish  yellow,  and  more 
frequent,  often  five  or  six  times  per  hour.  After  treatment, 
patient  recognised  me  and  said  that  she  felt  better,  and  then  went 
to  sleep.    Pulse  100.     Gentle  stomach  exercise  added  to  treatment. 

9  p.m.  Temperature  101"3°,  pulse  100.  Diarrhoea  not  quite 
so  frequent,  three  or  four  times  an  hour  between  4  and  6  p.m., 
then  only  about  twice  an  hour.  Treatment ;  temperature  100'8° 
and  pulse  85  after  it  was  over. 

August  21. — Patient  slept  badly.  About  six  greenish-brown 
diarrhoeic  motions  during  the  night. 

11  a.m.  No  headache,  but  patient  very  tired.  Temperature 
97-7°,  pulse  74.     Treatment. 

Evening,  8  p.m.  Patient  had  had  no  diarrhoea  from  9  a.m. 
till  12  noon  ;  then  five  or  six  times  between  12  and  3.  Then  no 
more  ;  and  after  3  o'clock  she  had  been  able  to  sit  up  and  read  the 
newspaper.  Temperature  98'6°,  pulse  65.  Treatment.  After  it 
was  over,  patient  ate  some  bread  and  butter  and  dranl<  some 
milk  for  supper. 

August  22. — Patient  slept  well,  and  ate  her  usual  breakfast 
during  the  morning.  She  said  that  she  felt  quite  well  though 
weak.  No  motion  since  3  p.m.  the  previous  day.  Treatment 
once  with  a  few  active  exercises,  general  nerve  treatment, 
stomach  exercise,  &c. 

August  23. — Two  normal  motions  during  the  day.  Treat- 
ment once  during  the  morning.  Appetite  normal.  Patient  said 
that  she  felt  quite  well  and  strong.     Treatment  finished. 

October,  1902. — Patient  had  been  quite  well  ever  since  her 
illness,  and  went  through  a  normal  confinement  (her  third)  in 
September,  1901. 

August,  1903. — Still  keeping  quite  well. 

Chronic  Appendicitis. 

Mr.  W.,  aged  22,  came  under  the  manual  treatment  on 
August  27,  1900,  on  the  advice  of  Dr.  Engstrand  (the  head 
medical  man  in  Joukoping). 

History  of  present  illness. — Early  in  1899  he  had  his  first 
attack  of  appendicitis.    His  medical  man  prescribed  morphia,  rest 


34S    ELEMENTS  OF  KELLCREN'S  MANUAL  TREATMENT 

in  bed  and  strict  dietary  precautions.  The  patient  got  over  the 
attack  rather  quickly,  remaining  in  bed  only  eight  days  ;  but  on 
first  getting  up  again  felt  very  weak.  He  never  felt  really  well, 
and  had  a  relapse  in  July  of  the  same  year,  the  second  attack 
being  about  as  bad  as  the  first.  He  had  another  relapse  in 
November,  and  a  third  in  the  middle  of  December.  Each  of 
these  attacks  lasted  about  eight  days,  the  treatment  adopted 
being  invariably  the  same.  On  December  26  he  tried  massage 
and  medical  gymnastics  (Ling's  system)  for  a  month ;  but  he 
had  three  further  relapses  during  that  time,  and  then  decided 
to  stop  the  gymnastic  treatment,  as  he  thought  it  was  doing 
him  harm.  Ever  since  1899  he  had  never  been  free  from  pain 
in  the  right  iliac  fossa,  the  pain  being  worse  just  after  every 
meal ;  and  he  suffered  chronically  from  constipation.  He  had 
become  markedly  thinner  since  the  first  attack.  He  remained  in 
much  the  same  low  condition  until  August  10,  1900,  when  he  had 
another  relapse,  which,  however,  was  not  so  bad  as  usual ;  on  this 
occasion  he  was  only  four  days  in  bed.  On  August  26,  Dr.  Eng- 
strand  recommended  the  patient  to  try  the  manual  treatment. 

Examination.- — Patient  was  thin,  pale  and  feeble  looking. 
He  complained  of  continual  pain  in  the  right  iliac  fossa,  most 
severe  just  after  meals.  His  appetite  was  bad,  and  he  suffered 
from  constipation,  a  motion  coming  on  an  average  only  every  third 
day.  There  was  considerable  tenderness  in  the  right  iliac  fossa, 
and  pressure  there  caused  pain.  The  thickened  vermiform  appen- 
dix, about  an  inch  in  diameter,  could  be  plainly  felt.  Patient 
slept  badly,  and  was  somewhat  depressed. 

Treatment. 

(1)  Half  lying  appendix  region  vibration,  kc,  PP. 

(2)  Side  span  standing  drawing  forwards,  PP,  kidney  fric- 
tions, PP. 

(3)  Side  lying  leg  lifting,  AE,  pressing  down,  PE. 

(4)  Sitting  trunk  extension  and  flexion,  PA. 

(5)  Stretch  stride  standing  bending  forwards,  PA. 

(6)  Forwards  lying  back  exercise,  PP. 

(7)  Stretch  span  standing  drawing  forwards,  PP,  abdominal 
intercostal  nerve  frictions,  PP. 

(8)  Heave  grasp  standing  chest  expansion,  PA. 


DISEASES   OF    THE   DIGESTIVE   ORGANS  349 

(9)  Eide  sitting  alternate  rotation,  AR,  ringing,  PP. 

(10)  Half  lying  stomach  exercise,  PP. 

Progress. — August  30. — Less  pain  in  the  right  iliac  fossa. 

September  7. — Patient  had  been  alternately  worse  and  better 
during  the  last  eight  days ;  on  this  day,  however,  he  felt  con- 
siderably better.  There  had  been  a  motion  every  day  since 
September  1. 

September  10. — Hardly  any  pain  in  the  right  iliac  fossa. 
Patient  said  that  he  felt  stronger. 

September  '26. — Patient  was  obliged  to  stop  the  treatment 
to-day.  His  general  condition  was  considerably  improved  ;  he 
felt  stronger  and  slept  better ;  also  his  appetite  was  better.  A 
motion  took  place  every  day.  There  was  no  tenderness  over  the 
right  iliac  fossa,  and  the  thickened  vermiform  appendix  had  quite 
disappeared ;  that  region  of  the  abdomen  was  apparently  quite 
normal. 

October  13. — In  reply  to  a  letter  of  mine,  patient  wrote, 
"  I  find  myself  in  very  good  health,  and  the  pains  in  my  abdomen 
with  which  I  was  specially  troubled  are  now  quite  insignificant. 
The  last  few  days  I  have  been  troubled  with  diarrhoea  from  which 
I  have  quite  recovered.     On  the  whole  I  feel  very  well  and  strong." 

Constipation. 

The  objects  of  the  manual  treatment  as  applied  to  constipa- 
tion are  as  follows  : — 

(1)  To  improve  the  laxness  of  the  anterior  abdominal  muscles ; 
the  latter  are  nearl}'  always  found  to  be  weak  and  thus  easily 
allow  dilatation  of  any  portions  of  the  intestine.  By  improving 
the  strength  of  these  muscles  such  dilated  portions  of  the  intes- 
tine are  reduced  in  size,  and  the  circulation  through  the  abdomen 
is  promoted. 

Increase  of  strength  in  the  anterior  abdominal  muscles  in 
all  probability  also  acts  reflexly  in  a  stimulatory  way  on  the 
abdominal  contents. 

(■2)  To  improve  the  circulation  in  the  abdomen  and  bring  more 
arterial  blood  to  the  weakened  intestine. 

(3)  To  stimulate  the  intestinal  muscle  to  contraction ;  this 
will  in  its  turn  promote  the  venous  flow,  promote  absorption  by 
the  lymphatics,  cause   the   intestinal  contents  to  pass  on  more 


3 so     ELEMENTS  OF   KELLGREN'S   MANUAL    TREATMENT 

quickly,  and  improve  the  flow  of  intestinal  juice.     All  this  reacts 
in  its  turn  in  a  stimulatory  way  on  the  intestine. 

Case  1. 
(From  notes  taken  by  Dr.  A.  Moller  and  myself.) 

Miss  P.,  aged  35,  came  under  the  manual  treatment  on 
November  15,  1899. 

History  of  present  illness. — Patient  has  been  suffering  from 
chronic  constipation  since  1881,  occasionally  getting  better  for  a 
few  months,  and  then  becoming  worse  again.  Patient  informed 
me  that  she  had  been  taking  pills  fairly  constantly  during  the 
last  eleven  3'ears,  and  had  had  perpetually  to  resort  to  enemas,  &c. 
She  had  had  no  motion  for  several  days,  and  of  late  eight  days 
had  often  elapsed  without  one  taking  place.  She  likewise  com- 
plained of  severe  headache  and  was  nervous  and  depressed. 

The  treatment  was  as  follows  : — 

(1)  Reach  grasp  step  standing  knee  flexion  and  extension,  PA, 
sacral  beating,  PP. 

(2)  Stretch  grasp  standing  drawing  forwards,  PP,  abdominal 
intercostal  nerve  frictions,  PP. 

(3)  Stretch  stride  standing  bending  forwards,  PA. 

(4)  Sitting  trunk  extension  and  flexion,  PA. 

(5)  Forwards  lying  back  exercise,  PP. 

(6)  Sitting  head  exercise,  PP. 

(7)  Loin  lean  stride  standing  alternate  rotation,  AE,  ringing, 
PP. 

(8)  Stretch  half  lying  running  nerve  frictions,  PP,  side 
shaking,  PP. 

(9)  Half  lying  leg  rolling,  PP,  flexion,  PA,  extension,  AR. 
(10)  Half   lying   stomach  exercise,   including  frictions  on  the 

ganglion  impar,  PP. 

Patient  was  ordered  to  stop  all  medicine,  enemata,  &c. 

Progress. —  November  17. — Headache  disappeared,  and  did  not 
return  during  the  month  patient  remained  under  treatment. 

November  20. — Normal  motion. 

November  22. — Motion.  After  that  patient  had  a  motion 
almost  every  day  until  November  28.  Then  none  until  November 
30,  during  menstruation.  After  that  daily  until  December  15. 
Treatment  then  stopped,  patient  feeling  very  well. 


DISEASES   OF    THE   DIGESTIVE   ORGANS  351 

She  remained  so  until  the  middle  of  January  1901,  when  she 
gradually  became  constipated  again  ;  her  headaches  returned  also. 

She  came  back  to  me  on  May  14,  1900,  with  recurrence  of 
the  headache  and  constipation ;  she  had  not  had  a  motion  for 
five  days.  The  treatment  was  resumed,  the  gymnastic  pre- 
scription being  practically  the  same  as  before.  After  the  first 
day  of  treatment,  her  headache  disappeared  and  did  not  return  ; 
she  had  a  motion  on  the  same  day  and  also  on  May  16.  She 
continued  the  treatment  until  June  '20,  and  had  a  motion  daily 
from  May  16  until  then  with  only  two  exceptions,  on  May  '24 
and  June  5. 

September,  1900. — I  heard  that  patient  was  keeping  quite 
well  and  had  a  motion  daily. 

In  this  case  I  made  the  observation  that  frictions  on  the 
ganglion  impar  produced  at  first  no  sensation ;  as  improvement 
took  place,  this  sensation  returned,  and  after  about  three  weeks 
a  kind  of  lightning  feeling  began  to  be  felt  throughout  the  abdo- 
men when  the  frictions  were  executed. 

Case  2. 

G.  A.,  aged  9,  had  been  constipated  almost  since  birth. 
Temporary  improvement  took  place  when  he  underwent  the 
treatment  for  facial  paralysis  two  years  previously,  due  no  doubt 
to  the  exercises  for  improving  the  condition  of  the  body  in 
general  ;  but  after  it  was  over  he  relapsed  again  into  his  former 
condition.  Often  three  days  would  pass  without  an  evacuation, 
upon  which  his  mother  would  administer  an  enema,  which  would 
produce  the  desired  effect.  He  did  not  suffer  from  any  special 
symptoms  in  consequence  of  this,  although  he  was  thin,  small, 
and  rather  undersized  for  his  age.  The  treatment  was  adminis- 
tered daily  from  June  23  to  July  31,  1900  ;  the  constipation 
entirely  disappeared,  a  rectal  evacuation  taking  place  daily  during 
the  last  fortnight  of  the  period  specified.  In  September,  1902, 
patient's  bowels  were  still  acting  regularly. 

The  treatment  was  on  the  lines  already  indicated. 

Chronic  Intestinal  Catarrh. 

A.  E.,  aged  4.5,  male,  came  under  the  manual  treatment  on 
July  29,  1902. 


352      ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

Historji  of  ivesent  illness. — Patient's  motions  had  for  some 
years  ever}'  now  and  then  been  loose,  although  he  could  not  say 
that  he  actually  suffered  from  diarrhoea.  During  the  summer  of 
1901,  however,  the  looseness  developed  into  diarrhoea,  and  during 
the  month  of  August  he  passed  daily  some  two  or  three  diarrhoeic 
motions.  He  was  unable  to  ascribe  any  cause  for  this  change. 
The  condition  got  steadily  worse  ;  and  from  January,  1902,  on- 
wards he  would  have  as  many  as  four  or  five  motions  between 
5  a.m.  and  9  a.m.,  and  as  many  more  during  the  rest  of  the  day. 
In  January  the  motions  were  still  brownish  in  colour,  but  then 
gradually  paled  to  yellowish-brown,  becoming  also  more  watery. 
During  March  they  became  the  colour  of  pea  soup,  and  from  June 
onwards  were  even  of  a  lighter  yellow.  Patient  had  steadily 
become  weaker  and  thinner  during  the  last  four  or  five  months. 

Examination. — Patient  had  no  pain  in  the  abdomen,  and  his 
clothes  did  not  irritate  the  skin  of  this  region.  He  noticed  very 
much  gurgling  in  his  abdomen,  especially  during  the  morning. 
He  had  had  a  dry  cough  for  some  years  past,  especially  during 
spring  and  autumn,  and  the  attack  of  coughing  often  terminated 
with  a  vomit ;  he  did  not  vomit  otherwise.  His  appetite  had 
remained  good. 

The  motions  were  now  very  watery  indeed,  and  light  yellow 
in  colour,  with  an  unpleasant  odour.  Patient  had  never  noticed 
any  blood  in  them.  Some  tenderness  was  manifested  on 
administering  stomach  exercise,  and  loud  gurgling  sounds  were 
heard  meanwhile.  The  liver,  however,  was  very  insensitive  to 
pressure  below  the  costal  margin,  and  to  frictions  on  the  gall- 
bladder ;  and  there  was  less  sensation  while  receiving  frictions  on 
the  sixth  and  seventh  dorsal  nerves  on  the  right  side  posteriorly 
near  the  si^inal  column  than  while  receiving  them  on  the  rest  of 
the  spinal  nerves,  which  on  the  whole  were  rather  more  than 
usually  sensitive,  especially  the  ninth  to  twelfth  dorsal  nerves. 

Patient  had  been  steadily  losing  weight  during  the  last  few 
months,  and  had  felt  continually  tired  and  weak.  His  weight 
was  54  kilos,  at  the  time  of  examination. 

Treatment. 

(1)  Stretch  grasp  standing  drawing  forwards,  PP,  liver  and 
gall  bladder  frictions,  and  frictions  on  the  right  sixth  and  seventh 
dorsal  nerves  near  the  spine,  PP. 


DISEASES   OF   THE   DIGESTIVE   ORGANS  353 

(2)  Half  lying  double  arm  rolling,  PP,  bending  and  stretchuig, 
AE. 

(3)  Loin  lean  stride  standing  alternate  rotation,  AR,  ringing, 
PP. 

(4)  Stretch  side  lying  running  nerve  frictions,  PP,  liver  and 
right  sixth  and  seventh  dorsal  nerve  frictions,  PP. 

(5)  Lying  double  leg  flexion  and  extension,  PA. 

(6)  Hip  lean  walk  standing  lateral  flexion,  PR,  extension,  AR. 

(7)  Heave  grasp  standing  chest  clapping,  PP,  side  shaking,  PP. 

(8)  Half  lying  abdomen  vibration,  PP. 

(9)  Half  lying  stomach  exercise,  frictions  on  the  abdominal 
sympathetic,  PP. 

Progress. — Patient's  condition  steadily  improved. 

August  13. — Only  two  loose  motions  between  5  a.m.  and 
9  a.m  ;  two  more  during  the  course  of  the  day.  They  were 
browner  in  colour. 

August  28. — The  motions  had  diminished  to  two  loose  ones 
before  breakfast  and  none  during  the  rest  of  the  day  ;  they  were 
of  normal  colour.     Patient's  weight  -55  kilos. 

September  80.— The  daily  number  of  motions  continued  to  be 
no  more  than  two,  which  were  of  normal  colour  and  consistence. 
Patient's  weight  59y  kilos.  Patient  felt  quite  well  and  strong. 
Sensation  along  the  liver  and  in  the  corresponding  spinal  nerves 
was  normal.     Treatment  finished. 

Diarrhcea. 

L.  J.  T.,  solicitor,  aged  29,  came  under  the  manual  treatment 
on  February  6,  1903. 

Histonj  of  present  illness. — On  February  2  patient  felt  very 
tired  all  day  ;  during  the  morning  he  vomited  his  breakfast, 
and  diarrhoea  commenced,  compelling  him  to  evacuate  every 
hour.  Patient  felt  that  the  motions  were  watery,  but  did 
not  notice  their  colour.  He  ate  nothing  all  day,  but  was  still 
able  to  attend  to  business.  February  3. — Patient  remained 
in  bed  all  day  ;  he  felt  very  weak,  and  had  a  continued 
feeling  of  diarrhcea ;  light  coloured  watery  motions  occurred 
every  hour  or  so  during  the  day  and  every  third  hour  during 
the  night.  There  was  no  vomiting.  Patient  ate  practically 
nothing,  and  took  chalk  mixture  three  times  during  the  day. 
23 


354      ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

February  4. — Patient  was  a  little  better  ;  he  had  a  con- 
tinued feeling  of  diarrhoea,  but  managed  to  control  it  so  that 
there  were  only  three  motions  during  the  course  of  the  day. 
His  appetite  was  slightly  better,  and  he  ate  a  little  boiled  cod  for 
lunch;  chalk  mixture  t.i.d.  February  5. — Condition  the  same; 
diet  the  same  as  during  the  previous  day.  Patient  felt  so  weak 
that  he  took  some  brandy  during  the  evening.  Chalk  mixture 
t.i.d.  February  6. — Condition  unchanged.  I  was  called  in  at 
6  p.m. 

Treatment. — Vibrations  over  the  abdomen,  gentle  stomach 
exercise,  spinal  nerve  frictions.  Patient's  appetite  returned 
after  treatment ;  he  ate  some  beef  and  drank  a  bottle  of  beer. 
Normal  motion  during  the  evening. 

February  7. — Patient  felt  quite  well  again,  appetite  normal : 
diet  as  usual.  No  motion  at  all  during  the  day.  Treatment  for 
the  last  time. 

February  8. — Normal  motion  during  afternoon. 

May  28,  1903. — I  saw  patient  again  ;  he  bad  been  quite  well 
ever  since  his  attack. 


CHAPTER  VI. 

HEART    DISEASES. 

Heart  diseases  were  treated  by  P.  H.  Ling,'  Branting,' 
Georgii,'  Rothstein,*  Neumann,"  Richter,^  Eulenburg,'  Melicher,** 
Hj.  Ling,^  Hartelius,^"  and  others.'^ 

The  objects  of  the  manual  treatment  as  applied  to  heart 
disease  are  as  follows  : — 

I. — To  enable  the  heart  to  act  better  by  promoting  the  circula- 
tion and  stimulating  the  heart  directly. 

'  "  Gymuastikens  Allmanna  Grunder,"  (1831)  1840,  pp.  172,  &c.  See  also  Mass- 
jnann,  "P.  H.  Liug'.s  Schrifteu  liber  Leibesiibungen,"  1847,  pp.  75,  76. 

- "  Efterleninade  Skrifter,"  1882,  gj-muastic  prescriptions  for  1840,  et  seq. ; 
"  Arsrapport  till  Kongl.  Sundhets-Kollegium  ar  1861,"  1863,  pp.  34,  &c.  See  also 
Both,  "Handbook  of  the  Movement  Cure,"  1856,  pp.  276,  367. 

^ "  Kinesitherapie,"  1847,  p.  50;  "Kinetic  Jottings,"  1880,  pp.  168-173, 
197-199,  &c. 

' "  Die  Gymnastik  nach  dem  Systeme  des  Schwedischen  Gymnasiarcheu  P.  H. 
Ling,"  1847,  pp.  93,  102105 ;  "  Nachrichten  iiber  das  Schwedische  Centralinstitut 
fiir  die  Gymnastik,"  in  Athencpum  fiir  jRationelle  Gymnastik,  vol.  iii.,  1856,  pt.  2, 
p.  141. 

^"Therapie  der  Chrouischen  Krankheiten,"  1857,  pp.  314-316;  "  Lehrbruch  der 
Leibesiibungen,"  1856,  pt.  2,  pp.  -302,  &c.  ;  "  Bericht  iiber  das  erste  Jahr,"  &c.,  in 
Athen.  f.  Rat.  Gym.,  vol.  i.,  1854,  pt.  1,  p.  263;  "Die  Einftihruugder  Heilgymnastik 
iin  Lazareth  uud  Klinik,"  ibid.,  vol.  ii.,  pt.  1,  p.  1 ;  "  Bericht  iiber  das  zweite  Jahr," 
&c.,  ibid.,  vol.  ii.,  1855,  pt.  2,  p.  256.  See  also  Roth,  "  Handbook  of  the  Movement 
Cure,"  1856,  p.  277. 

'  "  Die  Neuere  Heilgymnastik  "  in  Schmidt's  Jahrbiicher,  vol.  Ixxxii.,  1854,  p.  248. 

'  "  Die  Lingsche  oder  Schwedische  Heilgymnastik  "  in  Goschen's  Deutsche  Klinik, 
1852,  p.  350. 

'  "  Erster  Bericht."  1853  ;  "  Jahresbericht  fiir  1853  " ;  "  Jahresbericht  fiir  1854  "  ; 
"  Jahresbericht  fiir  1855"  ;  "Jahresbericht  fiir  1856  und  1857." 

■'Preface  to  Branting's  "  Eftsrlemnade  Skrifter,"  1882,  p.  xxxix. 

'"  "  Om  Sjuligymnastiken  vid  Gymnastiska  Central  Institutet  under  ar  1863,' 
1864,  pp.  32-42,  78;  "Gymnastiska  lakttagelser,"  1865,  pp.  69-73,91;  "Arsberiit- 
telse  i  Sjukgymnastik  "  &c.,  in  Svenska  Gymnastik-Fureninrjens  Tidskrift,  1866,  p.  49 ; 
*'  Kort  PramstiiUning  om  Sveuska  Gymnastiken  ....  under  aret  1870,"  1871,  p.  22  ; 
"Larobok  i  Sjukgymnastik,"  1870,  pp.  193-211;  1883,  pp.  197-225;  1892,  pp.  194- 
221;  "  Gymnastiska  Notiser,"  1872,  p.  20;  in  Hf/jjea,  1877,  pp.  145-154 ;  "Ofversigt 
af  patienter  behaudlade  .  .  .  .  ar  1884,''  in  Tidskrift  i  Gyimuistik,  1885,  pt.  5, 
p.  293  ;  "  Den  Mekaniska  Agentens  Porhallande  till  Hjertsjukdomar,"  ibid.,  1886, 
pp.  408,  &c.,  469,  &c. 

"  See  for  example  Miinchenberg,  "  Zweiter  Bericht,"  &c.,  in  .ithen.  f.  Bat.  Gym., 
vol.  ii. ,  1885,  pt.  4,  pp.  319,  &c. 


356  ELEMENTS  OF  KELLGREN'S    MANUAL   TREATMENT 

II. — To  improve  the  constitution  as  a  whole. 
Detailed  practical  consideration  of  the  above  • — 
I. — Under  this  heading  it  is  necessary  to  refer  briefly  to  the 
effects  of : — 

(1)  Respiratory  movements. 

(2)  Passive  movements  at  joints. 

(3)  Active  movements. 

(4)  Stomach  exercise,  PP. 

(5)  Manipulations  over  the  heart  itself  or  on  its  nerves. 

(1)  Bespiratory  movements. — In  the  case  of  most  cardiac  lesions 
respiration  is  rapid  and  shallow,  and  frequently  it  can  be  seen 
that  during  inspiration  the  abdomen  is  drawn  in.  This  means 
that  there  is  a  further  increase  in  the  already  existing  impedi- 
ments to  the  venous  and  lymph  return  in  consequence  of  the 
cardiac  lesion  (see  p.  126).  It  is  of  vital  importance  that  such 
patients  should  learn  to  breathe  correctly  as  soon  as  possible, 
and  such  passive  respiratory  movements  as  chest  lifting,  PP, 
&c.,  should  be  prescribed  at  once,  and  their  beneficial  effect  will 
not  fail  to  be  noticed. 

Chronic  diaphragmatic  spasm  can  also  be  relieved  by  means  of 
subcostal  shaking,  shaking  over  the  bladder  and  subdiaphragmatic 
suction. 

(2)  Passive  movements  at  joints.  —  These,  as  already  stated 
on  pp.  38  to  40,  promote  the  venous  and  lymphatic  flow,  and  in 
proportion  to  the  rate  and  radius  through  which  they  are  executed, 
bring  about  varying  degrees  of  vaso-dilatation  of  the  arteries. 
Thus  the  circulation  of  the  blood  will  be  promoted,  and  the 
peripheral  resistance  lowered. 

Passive  flexions  and  extensions  do  not  produce  such  a  wide- 
spread effect  as  rollings,  because  the  former  chiefly  affect  the 
flexor  and  extensor  surfaces,  whereas  the  latter  affect  also  the 
lateral  aspects  of  the  parts  exercised. 

The  effect  of  ringing,  PP,  on  the  abdominal  circulation  has 
been  referred  to  on  p.  88. 

(3)  Active  movements. — Duplicate  movements  are  generally 
administered  instead  of  purely  active  ones,  because  their  effect 
and  the  amount  of  muscular  energy  expended  is  better  graduated. 

It  has  already  been  stated  that  duplicate  movements,  proj^erly 
executed,  can  be  given  to  cause  no  extra  strain  on  the  heart, 
because  by  their  means,  although  the  muscles  actually  involved 


HEART    DISEASES  357 

contract  more  powerfully,  the  co-action  of  fixators  of  the 
neighbouring  joints  is  elimiziated,  and  the  patient  is  never  allowed 
to  forcibly  hold  his  breath  (see  pp.  33,  34). 

Hasebroek  ^  has  given  some  details  concerning  the  effects  of 
duplicate  movements  on  the  blood-vessels.  His  observations  were 
made  with  the  sphygmograph  and  sphygmometer.  He  found  that 
a  correctly  executed  duplicate  movement  brought  about  a  relaxa- 
tion (most  probably  also  a  vaso-dilatatiou)  in  the  peripheral 
arteries.  This,  in  the  majority  of  cases,  was  followed  by  an 
increase  in  the  pressure  until  the  maximum  was  reached,  after 
which  the  pressure  sank  to  a  point  below  what  it  was  before  tl^e 
movement  commenced  ;  it  then  slowly  returned  to  what  it  was 
originally.  The  initial  rise  in  pressure  was  not  due  to  vaso- 
constriction, but  to  increased  cardiac  action,  brought  about 
reflexly  by  impulses  from  the  active  muscles.  Thereupon  the 
vaso-dilatation  that  ensued  gave  the  heart  rest. 

In  consequence  of  the  vaso-dilatation  in  the  peripheral  parts, 
there  will  be  a  tendency  for  the  quantity  of  blood  in  the  heart,  if 
excessive  in  amount,  to  be  diminished,  and  thus  dilatation  of  the 
heart,  if  it  exists,  will  be  lessened. 

Thus  duplicate  movements,  if  carefully  executed,  result  in  a 
strengthening  of  the  cardiac  action,  and  a  lengthening  of  the 
diastolic  period  ;  a  beneficial  circle  is  set  up.  In  consequence  of 
the  improvement  in  the  cardiac  action  the  blood  is  pumped  more 
vigorously  through  the  lungs,  and  the  circulation  in  the  coronary 
arteries  (which  takes  place  during  diastole  of  the  ventricle)  has 
more  time  for  its  adequate  performance.  Diminution  in  the 
diastolic  distension  of  the  left  heart  also  favours  the  flow  in  the 
coronary  arteries.     All  this  reacts  beneficially  on  the  heart. 

In  short,  carefully  executed  duplicate  movements  quiet  the 
heart's  action. 

Patients  who  are  not  strong  enough  to  execute  duplicate  con- 
centric movements  can  often  quite  well  execute  duplicate  excentric 
movements,  which  almost  entirely  eliminate  any  tendency  to 
temporary  extra  strain  on  the  heart.  In  the  case  of  very  serious 
lesions  passive  movements  only  remain  possible. 

(4)  Stomach  exercise. — The  effects  of  this  have  been  already 


'  "  Uber  die  Gymuastisohe  Widerstandsbewegungen  in  der  Therapie  der   Herz- 
kraakheiten,"  1895. 


358    ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

described  at  full  length  :  I  will  therefore  only  suinniarise.     They 
are  as  follows  : — 

(a)  Promotion  of  the  arterial  and  venous  flow  in  the  abdomen. 

(b)  Vaso-dilatation  in  the  arteries. 

The  further  efifect  of  the  above  will  be  promotion  of  the 
abdominal  circulation  and  diminution  in  the  peripheral  resistance. 

(c)  Eeflex  quietinf^  of  the  cardiac  action. 

(fZ)  Diminution  of  reflex  contraction  of  the  abdominal 
muscles  if  such  exists,  thus  improving  the  muscular  respiratory 
mechanism. 

(.5)  Manipulations  over  the  heart  itself  or  on  its  nerres. 
These  are  as  follows: — Shaking  and  vibration,  clapping  and  hack- 
ing over  the  heart  ;  frictions  on  the  left  fourth  and  fifth  dorsal 
nerves  near  the  spinal  column,  and  hacking  on  the  shoulders. 
The  effects  of  these  have  already  been  considered  in  detail. 

II. — Under  this  heading  falls  the  consideration  of  the  effects 
of  some  of  the  movements  already  discussed,  i.e.,  respiratory 
exercises,  passive  flexions  and  rollings,  purely  active  and  duplicate 
movements,  stomach  exercise  ;  also  of  manipulations  that  stimu- 
late the  cerebro-spinal  system  as  a  whole,  and  those  that 
stimulate  the  kidneys,  spleen,  &c. 

It  should  here  be  mentioned  that  the  spleen  in  some  cases  of 
heart  disease  is  tender,  even  when  no  signs  exist  of  back  pressure 
in  the  caval  or  portal  system.  Executing  spleen  frictions  or 
vibrations  and  frictions  on  the  left  ninth  and  tenth  dorsal 
nerve  near  the  spine  will  often  relieve  the  patient,  and  in 
one  case  I  noticed  that  the  pulse  rate  sank  from  five  to  six  beats 
per  minute  more  at  the  conclusion  of  the  daily  gymnastic  treat- 
ment if  this  si^leeu  treatment  was  included  than  if  it  was  omitted. 

Ling's  system  is  hardly  ever  found  mentioned  in  connection 
with  gymnastic  treatment  for  heart  disease,  although  frequent 
references  occur  to  two  others,  viz.,  Oertel  and  Schott.  It  is 
necessary  to  consider  briefly  the  methods  of  these  two  latter. 

Oertel's '  treatment  consists  in  reducing  the  amount  of  liquid 
food  taken,  in  dietary  precautions,  in  graduated  uphill  exercise 
and    a  kind  of  respiratory  exercise  executed  with  lateral  com- 

'  See  Oertel's  "  Aligemeine  Tlierapie  der  KreislaufsstoriingeD,"  1885  (vol.  iv.  of 
V.  Ziemssen'.s  "  Handbuch  der  AUgemeinen  Therapie  ")  and  "  Massage  des  Herzens," 
1889,  &o. 


HEART    DISEASES  359 

pressioii  of  the  thorax  during  expiration.  His  method  is,  how- 
ever, obviously  inapphcable  to  serious  cases,  such  as  involve  the 
patient  keeping  in  bed. 

Schott's  treatment  is  one  which  has  received  a  good  deal  of 
attention  of  late.  The  method,  however,  is  not  the  invention  of 
Schott,^  in  spite  of  his  asssertions  that  it  is.  The  movements 
specified  by  Schott  are  a  few  of  the  most  elementary  ones  of 
Ling's  system  executed  without  due  regard  either  to  the  initial 
position  or  to  respiration  ;  and  Schott  prescribes  no  passive  move- 
ments of  joints,  no  chest  expanding  ones,  no  local  heart  treatment 
and  no  passive  circulatory  furthering  movements  for  the  abdomen. 
These  defects  in  the  gymnastic  methods  are  to  some  extent 
remedied  by  the  use  of  carbonic  acid  baths. 

Why  these  two  methods  should  have  become  so  popular  and 
widely  known  at  the  expense  of  other  and  better  ones  is  not 
intelligible. 

Case  1. 

Mitral  Incompetence. 

J.  H.,  aged  18,  came  under  the  manual  treatment  on  July  20, 
1900. 

History  of  prese)it  illness. — Four  years  previously  he  had 
suffered  rather  severely  from  rheumatic  fever,  his  heart  being 
affected  in  consequence.  The  cardiac  condition  was  how- 
ever not  very  bad,  and  four  months  after  the  beginning  of 
his  illness  he  was  able  to  resume  his  lathe  work  in  Huskvarna 
factory.  He  consulted  many  medical  men  about  his  heart, 
and  from  time  to  time  took  various  medicines,  which,  how- 
ever, did  him  no  good.  His  condition  remained  the  same 
until  about  November,  1899,  when  he  began  to  feel  worse,  and 
suffered  from  dyspnoea,  which  was  greatly  increased  on  exer- 
tion ;  some  cough  set  in.  At  Easter,  1900,  he  was  compelled 
to  stop  work  at  the  factory. 

Examination. — Patient  looked  weak  and  thin ;  his  lips  were 
somewhat  cyanosed.  He  complained  of  a  sense  of  oppression  and 
continual  uneasiness  in  the  cardiac  region,  and  sometimes  of 
attacks  of  palpitation  ;    also  of  coughing  a  good  deal,  bringing  up 

-Sec  Th.  Schott,  "  Zur  Behandlung  der  Fettherzens,"  a  paper  read  at  the 
Eleventh  Interaat.  Med.  Congr.  at  Rome,  1894  ;  "  tjber  Behandlung  Chronischer 
Herzkrankheiten  im  Jugendlichen  Alter,"  1899  ;  see  the  references  on  p.  355. 


36o      ELEMENTS  OF  KELLGREN'S  MANUAL  TREATMENT 

frothy  matter.  His  sleep  remained  fairly  good.  He  suffered  from 
breathlessness,  which  on  slight  exertion  became  much  worse  ; 
even  walking  at  a  moderate  pace  had  this  effect. 

The  fourth,  fifth,  and  sixth  ribs  on  the  left  side  in  the  cardiac 
region  were  prominent,  and  hypertrophied  for  about  2  inches 
in  their  course ;  over  this  area  cardiac  pulsation  could  be  both 
seen  and  felt.  There  was  a  heaving  impulse  in  the  fourth,  fifth 
and  sixth  interspaces,  and  the  apex  beat  was  most  prominent  in 
the  fifth  space,  1  inch  external  to  the  nipple  line.  A  thrill  was 
felt  over  this  area,  coincident  with  the  apex  beat.  Percussion 
showed  enlargement  of  the  heart  on  the  right  side.  A  loud  blow- 
ing murmur,  replacing  the  first  sound,  and  propagated  into  the 
axila,  was  audible  in  the  mitral  area ;  the  second  sound  was 
clear  in  this  area.  There  was  marked  accentuation  of  the  second 
sound  in  the  pulmonary  area.  The  aortic  and  tricuspid  sounds 
were  clear. 

Pulse  120  per  minute,  fairly  regular  ;  sphygmographic  tracing, 
taken  before  treatment,  is  shown  in  fig.  110. 


The  respiration  was  shallow.  The  lower  ribs,  as  tested  by 
means  of  side  shaking,  were  hard,  resistent  and  inelastic.  The 
abdominal  muscles  were  contracted,  and  did  not  move  with  respi- 
ration ;  on  asking  the  patient  to  make  a  deep  inspiration,  the 
upper  part  of  the  thorax  moved  most,  the  abdominal  muscles 
being  drawn  in. 

Appetite  not  good.     Motion  daily.     Urine  normal. 

While  this  case  was  under  my  charge  I  ascertained  the  pulse 
rate  both  before  and  after  treatment,  as  follows  : — I  requested  the 
patient  to  come  a  little  earlier  than  the  time  originally  appointed, 
and  to  sit  down  and  keep  quiet  until  I  was  ready.  I  then  placed 
him  in  half  lying  position,  waited  two  minutes  for  the  pulse  to 
become  regular  and  quiet  again,  and  then  counted  it.  The 
gymnastic  treatment  was   then   administered,    and  after  it    the 


HEART   DISEASES 


361 


pulse  was  counted  again,  the  patient  being  in  half  lying  position 
as  before. 

Treatment  as  follows  :  — 

(1)  Plalf  lying  double  arm  rolling,  PP,  bending  and  stretching, 
AK 

(2)  Forwards  lying  back  exercise,  PP. 

(8)  Half  lying  double  foot  rolling,  PP,  flexion  and  extension, 
AK. 

(4)  Heave  grasp  standing  chest  clapping,  side  shaking,  PP. 

(-5)  Sit  lying  knee  flexion  and  extension,  PP,  extension,  AR, 
flexion,  PR. 

(6)  Loin  lean  stride  standing  alternate  rotation,  AR,  ringing, 
PP. 

(7)  Half  lying  double  leg  rolling,  PP,  flexion,  PA,  extension, 
AR. 

(8)  Half  lying  heart  shaking,  PP. 

(9)  Walk  standing  double  arm  circling,  breathing,  PA.  (This 
was  administered  at  intervals  several  times  during  the  daily 
course  of  treatment.) 

(10)  Half  lying  stomach  exercise,  PP. 

Progress. — The  pulse  rate  was  as  follows  : — 


Date. 

Before 
tre.itnieiit. 

After 
treatment 

July  21       

120 

102 

,,      23       

120 

100 

„      U       

125 

97 

„      25      

120 

90 

„      26      

110 

90 

„      27      

102 

86 

„      28      

100 

85 

,,      30      

95 

85 

August  1 

•2 

102 
88 

84 
84 

3 

90 

88 

i 

100 

90 

5 

100 

90 

6 

100 

90 

„        8 

98 

84 

„        9 

98 

88 

„      11 

87 

81 

,,      14 

81 

76 

„      20 

82 

78 

„      24 

80 

76 

„      30 

80 

74 

September  4 
8 

81 
80 

76 
72 

10 

80 

72 

„         14 

80 

72 

362     ELEMENTS    OF   KELLGREN'S   MANUAL    TREATMENT 

See   figs.    Ill    to    117    for   various  spbygiuographic   tracings 
taken  after  treatment. 


September  14. — Treatment  finished  to-day.  Patient  said  he 
felt  stronger ;  the  lips  were  no  longer  cyanosed.  He  could  walk 
quicker  without  any  breathlessness  ensuing,  and  moderate 
exertion  caused  none.      He  said  that   he  slept  better  and  ate 


HEART    DISEASES 


363 


better.  The  cough  had  ahuost  disappeared.  There  was  no 
sensation  of  oppression  or  uneasiness  in  the  cardiac  region.  The 
abdominal  muscles  moved  with  respiration,  and  were  much  less 
hard  and  tense.  The  lower  ribs  moved  to  a  greater  extent  with 
respiration,  and  were  more  elastic.  The  apex  beat  was  about 
half  an  inch  internal  to  the  nipple,  and  was  limited  to  the  fifth 
interspace.  Percussion  showed  a  very  slight  enlargement  to  the 
right  of  the  sternum.     The  murmur  was  as  before,  but  less  loud. 


Fig.  117 


There  was  still  accentuation  of   the  second  sound   in  the  pul- 
monary area. 

Patient  resumed  work  (lathe  work)  on  October  1.  1  saw  him 
again  on  November  12.  He  had  been  working  steadily  ever  since 
October  1.  He  was  feeling  very  well ;  no  unpleasant  symptoms 
had  arisen.     The  heart  dulness  and  sounds  were  as  before  ;  the 


364    ELEi\JENTS  OF  KELLGREN'S  MANUAL  TREATMENT 

pulse,   when  sitting  down,  was  82.     Spliygmographic  tracing  is 
shown  in  fig.  IIH. 

I  saw  patient  again  on  March  1,  1901.  Patient  had  been 
working  steadily  since  October  1,  1900,  and  said  that  he  felt 
even  better  than  when  I  last  saw  him  ;  he  was  stronger,  and 
could  work  better.      No  unpleasant  symptoms  had  arisen.      The 


size  of  the  heart  was  about  the  same  as  before,  the  apex  beat 
being  about  half  an  inch  internal  to  the  nipple  line.  The  mur- 
mur in  the  mitral  area  was  less  loud,  and  there  was  hardly 
any  accentuation  of  the  second  sound  in  the  pulmonary  area. 
Pulse,  when  sitting  down,  7'2  per  minute.  Sphygmographic 
tracmg  is  shown  in  fig.  119. 


Case  2. 
Mitral  Stenosis  and  Incompetence. 

H.  T.,  aged  13,  came  under  the  manual  treatment  on  October  1, 
1900. 

Historij  of  present  illness. — He  was  attacked  with  rheumatic 
fever  during  November,  1899,  and  was  in  bed  one  month.  In 
May,  1900,  he  had  another  attack,  and  was  treated  at  the  hospital, 
where  the  diagnosis  of  acute  articular  rheumatism  and  mitral 
incompetence  was  made.      He  remained  at  the  hospital  until  the 


HEART   DISEASES  365 

middle  of  June,  and  then  went  to  a  summer  health  resort ;  he 
did  not,  however,  get  rid  of  his  rheumatic  pains.  In  August  he 
went  through  an  attack  of  pleurisy  with  effusion,  which  was 
not  so  bad  as  to  necessitate  thoracocentesis ;  after  it  had  passed 
there  remained  continual  rheumatic  pains,  a  tendency  to  fever,' 
and  general  weakness. 

Examination. — The  patient  looked  weak  ;  his  lips  were  some- 
what cyanosed.  He  complained  of  continual  pains  in  his  wrist, 
finger  and  ankle-joints,  sometimes  also  in  the  knee-joints.  All 
these  joints  were  visibly  swollen,  and  were  very  tender.  There 
was  breathlessness  on  exertion,  and  difficulty  in  walking,  the 
latter,  however,  due  partly  to  the  pain  in  the  ankles  and  knees. 
Patient  had  no  subjective  cardiac  symptoms. 

The  apex  beat  could  be  seen  in  the  fourth  interspace,  three- 
quarters  of  an  inch  external  to  the  nipple  line.    Percussion  of  the 


right  border  shows  enlargement  to  the  right  of  the  sternum.  In 
the  mitral  area  there  was  a  presystolic  murmm',  and  the  first 
sound  was  replaced  by  a  blowing  murmur,  which  was  propagated 
into  the  axilla.  There  was  accentuation  of  the  second  sound  in 
the  pulmonary  area.  The  aortic  and  tricuspid  sounds  were  clear. 
The  pulse  was  rapid,  about  120  per  minute,  intermittent.  The 
greatest  number  of  intermittencies  I  ever  counted  was  fifteen  in 
one  minute,  but  as  a  rule  they  averaged  from  five  to  ten.  Sphyg- 
mographic  tracing  is  shown  in  fig.  120.  Great  tenderness  existed 
over  the  fourth  and  fifth  left  dorsal  nerves  near  the  spine.  No 
signs  of  the  pleurisy  remained.     Temperature,  99°. 

Treatment. 

(1)  Heave  grasp  standing  chest  expansion,  PA,  followed  by 
heart  shaking,  given  together  with  frictions  on  the  left  fourth 
and  fifth  dorsal  nerves  near  the  spine,  PP. 


366    ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

(2)  Heave  sitting  double  forearm  extension  and  Hexion,  AR. 

(3)  Forwards  lying  back  exercise,  PP. 

(4)  Side  lying  running  nerve  frictions,  kidney  frictions,  PP. 

(5)  Lying  double  leg  flexion,  PA,  abduction,  AR,  adduction,  PR. 
(0)  Ride  sitting  alternate  rotation,  AR,  ringing,  PP. 

(7)  Stretch  stride  standing  bending  forwards,  PA. 

(8)  Sitting  hand  and  finger  rolling,  PP,  flexion  and  extension, 
AR,  joint  kneading,  PP,  &c. 

(9)  Half  lying  stomach  exercise,  PP. 

Progress. — The  fever  ranged  from  99°  to  101°  for  a  few 
days;  then  the  temperature  became  normal  and  did  not  rise 
again.    After  October  15  it  never  went  above  99"5°  in  the  evening. 

October  3. — Fifteen  intermissions  in  the  pulse  in  five  minutes. 

October  G. — Hand  and  finger-ioints  less  swollen.     Three  inter- 


missions in  the  pulse  in  ten  seconds,  then  none  for  one  minute 
and  forty  seconds. 

October  10. — No  intermission  in  one  and  a  half  minutes. 

October  12. — No  intermission  in  two  minutes. 

October  1(5. — Pulse  commencing  to  be  slower.  No  rheumatic 
pains  in  fingers,  wrists  or  ankles. 

October  19. — Pulse  rate  again  somewhat  increased. 

October  28. — Patient  took  a  walk  of  three  hours.  Fingers, 
wrists  and  ankles  had  not  swollen  since  October  16,  and  did  not 
again  become  so. 

November  1. — Sphygmographic  tracing  taken  ;  depicted  in 
fig.  121. 

November  3. — Pulse  below  100  per  luinute  for  the  first  time 
since  October  1. 

November  7. — Patient  visited  Huskvarna  factory  and  was  on 
his  feet  three  hours. 

November  9  to  13. — No  intermission  in  five  minutes. 


HEART   DISEASES 


367 


November  14. — One  intermission  in  five  minutes. 
November  14  to  17. — No  intermission  in  five  minutes. 
November  18. — Treatment  finished. 


Pulse  rate. — Taken  after  treatment. 


120 

October  25 

115 

27 

118 

29 

114 

31 

115 

November  1 

118 

2 

115 

3 

110 

5 

102 

6 

102 

.■     7 

103 

8 

110 

12 

111 

14 

104 

16 

110 

18 

110 

no 

108 
110 
101 
102 
98 
102 
98 
9G 
92 
92 
94 
96 


The  pulse  as  taken  in  the  evening  from  November  12  to  18, 
averaged  from  95  to  90. 

Examination. — November  18.  Patient  felt  ver}-  well  and 
strong ;  could  walk  quickly,  and  even  run  about  a  little  without 
unpleasant  symptoms  arising;  had  been  bicycling  in  modera- 
tion. Appetite,  sleep  and  general  appearance  better.  Lips  not 
cyanotic  at  all.  No  subjective  cardiac  symptoms.  No  joint 
symptoms.     The  apex  beat  could  be  seen  in  the  fourth  interspace 


in  the  nipple  line.  Percussion  of  the  right  border  showed  hardly 
any  enlargement  to  the  right  of  the  sternum.  The  mitral  murmurs 
could  still  be  heard  and  there  was  accentuation  of  the  second 
sound  in  the  pulmonary  area.  Sphygmographic  curve  taken 
November  17,  see  fig.  122.  The  tenderness  over  the  left  fourth 
and  fifth  dorsal  nerves  was  very  slight. 


368     ELEMENTS   OF   KELLGREN'S    MANUAL    TREATMENT 

Subsequent  jn-ogrcss. — On  March  '24,  1901,  patient's  father 
wrote  as  follows: — His  son's  condition  was  very  good.  There 
had  been  no  return  whatever  of  the  rheumatic  pains.  The  boy 
was  out  during  most  of  the  day  and  played  with  other  boys.  He 
had  not  complained  of  any  feeling  of  fatigue  to  his  father  after  so 
doing.  His  pulse  was  usually  7-5  during  the  morning  and  90  to 
95  during  the  evening. 


Case  3. 
Mitral   Stenosis  and   Incompetence. 

A.  L.,  aged  16,  female,  came  under  the  manual  treatment  on 
August  21,  1902. 

History  of  present  illness. — -When  a  young  child  she  had  had 
chorea  three  times,  the  last  time  being  at  8  years  of  age,  and  after 
the  last  attack  her  medical  man  said  that  she  had  heart  disease, 
but  not  to  a  serious  degree.  No  cardiac  symptoms  troubled  her 
until  January,  1902,  when  she  had  influenza,  and  remained  in 
bed  for  a  month.  After  the  influenza  had  passed  off  she  was 
troubled  with  shortness  of  breath,  especially  on  exertion;  with 
a  feeling  of  oppression  in  the  cardiac  region  ;  and  also  with  a 
swelling  of  her  feet  and  hands,  which  came  on  during  the  after- 
noon and  got  worse  during  the  evening.  Her  condition  had  been 
getting  slightly  worse  during  the  past  two  months. 

Examination. — Patient  exhibited  the  typical  flushed  cheek 
and  look  of  mitral  disease.  There  was  a  slight  bulging  of  the 
precordia.  The  apex  beat  was  diffuse  and  heaving,  and  could  be 
seen  in  the  fifth  and  sixth,  and  also,  though  very  slightly,  in  the 
seventh  interspace,  extending  two  inches  below  and  one  inch 
external  to  the  nipple.  Percussion  showed  the  heart  to  be  en- 
larged to  its  left  side  and  also  to  the  right  of  the  sternum.  On 
palpation  in  the  mitral  area  a  presystolic  thrill  was  felt.  On 
auscultation  in  the  mitral  area  the  ordinary  first  sound  was  re- 
placed by  presystolic  and  systolic  murmurs,  the  latter  propagated 
into  the  axilla ;  the  second  sound  was  closed.  Auscultation  in  the 
pulmonary  area  revealed  a  reduplicated  first,  and  a  loud  slapping 
second  sound.     The  aortic  and  tricuspid  sounds  were  clear. 

Patient  was  free  from  cough.  Some  cedema  of  the  feet  and 
ankles  came  on  every  afternoon,  as  already  mentioned. 


HEART   DISEASES 


369 


After  patient  had  lain  down  for  ten  minutes,  the  pulse  was 
102  and  the  respiration  '20  Sphygmographic  tracing  taken  before 
treatment ;  see  fig.  123. 


7^_A_J^v 


Aug.   ^1-  Before  treatment 


Treatment. 

(V)  Half  Ij'ing  double  arm  rolling,  PP,  bending  and  stretch- 
ing, AE. 

(2)  Half  lying  side  shaking,  PP.  heart  shaking,  PP,  with 
frictions  on  the  left  fourth  and  fifth  dorsal  nerves  near  the  spine, 
PP. 

(3)  Forwards  lying  back  exercise,  PP. 

(4)  Stretch  stride  standing  bending  forwards,  PA. 

(5)  Half  lying  double  foot  rolling,  PP,  flexion  and  extension, 
AE. 

(6)  Heave  lean  standing  chest  expansion,  PA. 

(7)  Heave  grasp  standing  chest  clapping,  PP,  side  shaking, 
PP. 

(8)  Sit  lying  knee  extension  and  flexion,  PP,  extension,  AE, 
flexion,  PE. 

(9)  Half  lying  leg  rolling,  PP,  flexion,  PA,  extension,  AE. 
(10)  Half  lying  stomach  exercise,  heart  shaking,  PP. 

The  treatment  was  given  dail}'  until  September  20. 

Examination. —  Patient  no  longer  exhibited  the  typical 
look  of  mitral  disease,  and  her  general  condition  was  greatly 
improved.  She  suffered  very  little  from  shortness  of  breath,  and 
could  walk  as  fast  as  any  of  her  girl  school-friends  without 
getting  out  of  breath.  There  was  no  feeling  of  oppression  in 
the  cardiac  region  and  no  swelling  of  the  hands  or  feet. 

Heart. — The  apex  beat,  rather  heaving  in  character,  was 
limited  to  the  fifth  interspace  in  the  nipple  line.  There  was  no 
enlargement  to  right  of  sternum.  A  presystolic  thrill  could  be 
felt.     Auscultation    in   the    mitral   area    revealed    a    presystolic 

21 


370     ELEMENTS   OF   KELLGREN'S   MANUAL    TREATMENT 

murmur,  but  the  systolic  murmur  had  disappeared.  Auscultation 
in  the  pulmonary  area  revealed  no  reduplicated  first  sound  ;  the 
second  sound  was  slightly  accentuated.  After  patient  had  lain 
down  for  ten  minutes  the  pulse  was  78  and  the  respiration  IS. 
Sphygmographic  tracing  taken  September  18 ;  see  fig.  124. 


Case  4. 

Rheumatic  (?)  Pericarditis,  Cardiac  Dilatation,  and  Mitral 
Disease. 

E.  B.,  female,  aged  14,  came  under  the  manual  treatment 
on  August  1.5,  1902. 

Previous  history. — Patient  had  never  been  very  strong ;  she 
was  small  and  undeveloped,  had  always  had  a  rather  yellowish 
complexion  and  somewhat  purple  lips,  and  had  always  suffered 
from  breathlessness  on  exertion.  Her  heart  had  never  been 
examined. 

History  of  present  illness. — On  August  13  patient  was  attacked 
rather  suddenly  by  shooting  pains  in  the  arms  and  legs,  and 
sharp  stabbing  pains  in  the  region  of  the  heart ;  the  latter  pains 
disappeared  every  now  and  then,  and  when  present  were 
intensified  by  deep  respiration.  There  was  also  fever.  The 
following  day  patient's  condition  was  worse,  and  as  on  August  15 
it  was  still  worse,  I  was  called  in  the  same  morning. 

Examination. —  Patient  was  in  bed,  lying  on  her  back  ; 
she  said  that  she  was  unable  to  lie  on  her  side.  She  com- 
plained of  the  pains  already  specified.  Cyanosis  was  present ; 
the  parents  said  it  was  more  apparent  than  before  her  present 
illness.  There  was  a  certain  amount  of  bulging  of  the  precordia. 
The  heart  itself  was  dilated.  The  cardiac  impulse  was  visible  and 
palpable  from  sternum  to  nipple  and  from  the  left  third  rib  do%Mi 


HEART   DISEASES 


371 


to  the  left  sixth  rib  ;  percussion  revealed  an  increase  in  the 
dulness  to  the  right.  Presystolic  and  systolic  mitral  murmur 
audible,  the  latter  propagated  into  the  axilla ;  the  second  mitral 
sound  closed  and  slapping  ;  the  second  sound  in  the  pulmonary 
area  accentuated.  Aortic  and  tricuspid  sounds  clear.  No  cough 
or  oedema.  Temperature  108°,  pulse  141,  respiration  46.  Great 
tenderness  along  the  spinal  nerves  and  over  the  kidneys. 

Evening.  Patient  had  eaten  nothing  all  day,  and  was  some- 
what weaker.  Heart  about  the  same  as  during  the  morning. 
Temperature  103'5°,  pulse  150,  respiration  51.  (For  temperature, 
pulse  and  respiration,  see  separate  chart,  fig.  125.) 


*UG. 

SEPT 

DATE 

15  j  16  1 17 

IR 

IS 

?n 

PI 

2ZIZ3IE4 

25|26'2r  28129130131 

1      2 

3 

4iSI6|7l8l9llOI 

TIME 

M  EM   e!m   E 

fi   E 

1  E 

«  E 

\  E 

rr 

<   E 

»  E 

rt 

4   E'M  E 

<    Erl    E 

<  EM  E 

i  l\*   E 

<  E 

i  E 

\  E 

t  E 

4  EM   E 

)  EM  El 

F" 

Rectum 

/■ 

^ 

h 

\ 

J 

^, 

h 

A 

/ 

> 

A 

J 

/ 

/ 

r 

A 

/ 

/ 

/ 

A 

/ 

k, 

/ 

V 

/ 

/ 

t 

^^ 

A 

y 

\ 

/ 

\ 

/ 

^ 

^ 

U^ 

PULSE 

IM 

146    'EB    '144 
m-    «a     153 

m 

36 

n? 

32    134 
136   132 

32    128 

136'   IZ8 

36    135 
128'  136 

36 
138 

26 
141 

36   132 
129   1Z8 

40 
124 

120 
IZ2 

20   124   128 
I2S   126 

126 

120 

"I16 

IZO 

20 

12U 

RE5P 

28 

?.?, 

.1,5 

XI 

■M 

sr 

4B 

60 

bi 

58 

51 

t>tj 

4U 

54 

44 

44 

52 

4b 

66 

bS 

52 

54 

42 

4B 

4-2 

^ 

_ 

Treatment  morning  and  evening. 

August  16.  Morning.  Patient  had  hardly  slept  at  all,  and 
had  been  sitting  up  all  night  in  consequence  of  great  cardiac 
distress  ensuing  immediately  on  trying  to  lie  down.  Pain  in 
precordia  much  worse,  often  causing  patient  to  cry  out.  More 
pains  in  the  arms  and  legs  ;  considerable  dyspnoea,  the  larynx  and 
alse  nasi  working  with  respiration,  which  was  rapid  and  shallow. 
Cyanosis  more  marked.  Heart's  action  somewhat  irregular ; 
dilatation  greater,  the  area  of  the  impulse  being  more  diffuse  and 
extending  beyond  the  nipple ;  mitral  murmurs  as  before  ;  re- 
duplicated first  sound  in  pulmonary  area ;  aortic  and  tricuspid 
sounds  clear.  Between  the  nipple  and  the  sternum  was  audible 
pericardial  friction,  which  was  intensified  by  pressure  with  the 
stethoscope,  the  latter  procedure  causing  some  pain.    Treatment. 


372     ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

11  a.m.  "  Canter  rhythm  "  audible  between  the  nipple  and 
the  sternum.     Pulse  146.     No  treatment. 

3  p.m.  Patient  about  the  same.  Pulse  144,  respiration  55. 
Treatment. 

7  p.m.  Patient  worse.  Marked  orthopnoea,  more  cyanosis. 
Distension  of  abdomen,  and  great  tenderness  over  the  liver. 
There  had  been  no  motion  since  the  14th.  Pulse  150,  respira- 
tion 60.     Treatment. 

9  p.m.  Patient  somewhat  better.  Abdomen  less  distended  ; 
pain  less  and  pericardial  friction  less.     Pulse  144,  quite  regular. 

Patient  had  been  able  to  sleep  for  an  hour  during  the  day,  but 
had  eaten  nothing  beyond  a  piece  of  bread.     No  motion  yet. 

August  17. — Morning.  Patient  had  been  able  to  sleep  a  little 
during  the  night,  but  had  no  appetite.  Heart  better ;  friction 
less.  Mitral  murmurs  and  sounds  in  pulmonary  area  as  before. 
Dilatation  about  the  same. 

Afternoon.  Patient  somewhat  worse.  Pulse  144,  not  quite 
regular  ;  respiration  66.     Some  biscuits  eaten  at  6  p.m. 

Evening.  Patient  about  the  same.  Pulse  irregular.  No 
motion  during  the  day;  abdomen,  however,  no  longer  distended. 
Treatment  to-day  three  times. 

August  18. — I  was  sent  for  at  4  a.m.  as  patient  had  become 
rapidly  worse  since  about  midnight.  Patient  was  in  bed,  half 
sitting  up,  semi-conscious,  not  answering  unless  spoken  to  several 
times  in  succession ;  when  she  did  speak  it  was  only  in  a  whisper, 
and  after  great  effort.  The  complexion  was  bluish-grey,  the  lips 
very  dark  purple  ;  the  respiration  was  laboured  and  irregular,  72 
per  minute.  The  pulse  was  hardly  perceptible  ;  its  rate  was 
about  160  per  minute.  Heart's  action  very  irregular  and  inter- 
mittent, every  fourth  or  fifth  pulse  beat  being  lost.  Heart 
very  much  dilated  ;  diffuse  impulse  visible  from  second  to  sixth 
interspaces  from  sternum  to  one  inch  outside  nipple  line,  and 
pulsation  palpable  to  the  right  of  the  sternum  in  the  fourth  and 
fifth  interspaces,  and  in  the  left  side  up  to  just  below  the  clavicle. 
Presystolic,  systolic,  and  diastolic  mitral  murmurs ;  reduplicated 
first  and  accentuated  second  sounds  in  the  pulmonary  area ; 
these  could  be  quite  easily  felt  through  the  chest  wall  with  the 
finger.  Aortic  and  tricuspid  sounds  muffled,  though  closed. 
Pericardial  friction  the  same  as  during  the  previous  day.  No 
oedema  anywhere. 


HEART   DISEASES  373 

I  treated  patient  for  one  and  a  half  hours,  chiefly  with  heart 
vibration,  side  shaking,  and  stomach  exercise  ;  at  the  close  of  this 
period  she  was  better,  and  became  quite  conscious  ;  the  pulse  also 
was  stronger,  more  regular,  and  markedly  dicrotic  ;  rate  about  150 
per  minute. 

9  a.m.  Patient  somewhat  better ;  she  had  been  to  sleep  for 
an  hour.     Treatment. 

II  a.m.  Patient  still  better,  although  unable  to  speak  above 
a  whisper ;  she  ate  some  biscuits.  Heart's  action  stronger. 
Pulse  142,  respiration  60.     Treatment. 

4  p.m.  Pericardial  friction  ceasing;  less  cyanosis.  Pulse  138, 
respiration  58.     Treatment. 

9  p.m.  Patient  had  drunk  some  milk  at  8  p.m.,  and  was 
better.  Apex  beat  only  extended  just  beyond  nipple.  Pulse  still 
markedly  dicrotic  ;  very  few  beats  missed.     Treatment. 

Patient  had  lain  absolutely  still  during  the  whole  day,  except- 
ing while  eating  and  drinking,  and  even  the  latter  actions  entailed 
great  exertion.     No  motion. 

August  19. — 5  a.m.  Patient  had  been  sleeping  at  intervals 
until  about  3  a.m  ,  when  a  change  for  the  worse  took  place.  The 
heart  was  again  irregular,  with  frequent  missed  beats,  and  the 
pulse  very  dicrotic,  about  135  per  minute ;  the  respiration  was  44. 
Treatment  for  an  hour  of  same  kind  as  early  during  the 
previous  day. 

11  a.m.  Patient  better.  No  more  pain  in  the  arms  and  legs, 
although  still  a  good  deal  in  the  cardiac  region.  Pericardial 
friction  no  longer  audible.     Treatment. 

4  p.m.  Patient  still  better ;  she  ate  some  pudding  at  '2  p.m. 
No  more  dicrotism  ;  pulse  quite  regular.  Dilatation  and  murmurs 
as  before.  Aortic  and  tricuspid  sounds  no  longer  muffled.  Pulse 
144,  respiration  68.  A  good  deal  of  perspiration  during  the  day. 
Treatment.     Patient  drank  some  soup  at  8  p.m. 

9  p.m.  Patient  was  still  better,  and  her  expression  more 
lively.  She  was  able  to  move  about,  and  to  move  her  arms  and 
head  without  distress  ;  she  was,  however,  as  yet  unable  to  lie 
down,  and  had  to  keep  half  sitting  up.  The  apex  beat  could  not 
be  felt  or  seen  outside  the  nipple.  Treatment.  No  motion 
during  the  day. 

August  20. — -5  a.m.  Another  change  for  the  worse,  although 
not  so  marked  as  during  the  two  previous  days.  Pulse  irregular 
and  somewhat  dicrotic,  136  ;  respiration  56.     Treatment. 


374     ELEMENTS   OF   KELLGREN'S   MANUAL   TREATMENT 

11  a.m.  Patient  had  drunk  some  milk  and  eaten  some 
biscuits  at  9  a.m.  She  was  a  good  deal  better,  and  wished  to 
get  up  and  walk  about ;  but  on  attempting  to  do  so  found  that 
she  was  too  weak.  After  treatment  she  was  carried  out  of  doors, 
and  sat  in  an  armchair  for  one  and  a  half  hours.  She  still 
complained  of  pain  in  the  cardiac  region,  otherwise  was  fairly 
cheerful. 

8  p.m.  Patient  could  move  her  head  and  arms  quite  easily. 
There  was  less  cyanosis  and  dyspncea.  Pulse  140,  quite 
regular,  not  dicrotic ;  respiration  48.  Treatment.  Patient  con- 
sumed an  egg,  some  milk  and  biscuits  at  8  p.m. 

9  p.m.  The  parents  stated  that  patient's  face,  except  for 
some  emaciation,  looked  the  same  as  before  her  illness.  The 
complexion  was  yellowish,  and  the  lips  somewhat  purple.  The 
heart  was  as  dilated  as  during  the  previous  day  ;  the  sounds  and 
murmurs  were  also  the  same.  There  had  been  some  dry  cough 
since  the  early  morning ;  pulse  132,  fairly  regular.  I  took  a 
sphygmographic  tracing  (for  the  first  time)  before  treatment 
(see  fig.  1'26). 


Aug  20^-2  Before  treatment 


No  motion  during  the  day  ;  no  distension  of  abdomen. 

August  21. — 11  a.m.  Patient  had  slept  a  little;  she  was 
able  to  talk  again  above  a  whisper  without  distress. 

4  p.m.  Patient  had  sat  out  of  doors  from  12  to  3,  and  eaten 
some  biscuits  and  drunk  some  milk  at  2  p.m.  Pulse  138,  respi- 
ration 60.  Motion  at  6  p.m.  (first  since  August  14).  Pain  in 
cardiac  region  less  during  the  whole  day. 

9  p.m.  Heart  not  quite  so  dilated  ;  the  apex  beat  could  not 
be  felt  further  out  than  half  an  inch  internal  to  nipple  line. 
Murmurs  and  sounds  as  before.  Treatment  three  times  a  day 
henceforth. 

August  22. — 10  a.m.     Patient's  appetite  returning ;  she  had 


HEART   DISEASES 


375 


drunk  milk  and  eaten  biscuits  for  breakfast.  Improvement  in  all 
subjective  symptoms  ;  patient  able  to  move  easily  ;  she  had  even 
been  walking  about  for  a  few  minutes.  Less  pain  in  the  cardiac 
reo;ion ;  very  little  dyspnoea.  After  treatment  patient  sat  out  of 
doors  for  three  hours. 

3  p.m.  No  dyspnoea.  Cardiac  impulse  not  so  diffuse.  Patient 
had  consumed  some  fruit  soup  for  dinner. 

No  motion  during  the  day. 

August  23. — Morning.  Sleep  still  poor.  Patient  stronger; 
had  eaten  veal  and  bread  and  drunk  some  milk  for  breakfast.  She 
was  coughing  up  a  good  deal  of  frothy  mucus.  No  cardiac  pulsa- 
tion in  the  first  interspace,  otherwise  the  condition  of  the  heart 
was  the  same  as  before.     Pulse  132,  quite  regular. 

Patient  was  up  and  walked  about  for  half  an  hour  during  the 
morning.     Dinner  at  2  p.m.,  bread  and  milk. 


4  p.m.  Pulse  13.5,  respiration  .57.  Supper  at  8  p.m.,  bread 
and  milk. 

9  p.m.  Patient  could  now  He  on  her  side  without  distress. 
No  pulsation  to  right  of  sternum.     No  motion  during  the  day. 

Treatment  twice  a  day  henceforth. 

August  24.— Morning.  Patient  sat  up  during  most  of  the 
day,  and  walked  about  a  good  deal.  Food :  milk,  bread  and 
porridge.  Motion  during  the  day.  Sphygmographic  tracing 
taken  before  evening  treatment  (see  fig.  127). 

During  the  ensuing  four  days,  the  heart  remained  about  the 
same  in  size,  although  its  action  gradually  became  stronger. 
Motion  henceforth  usually  daily,  although  sometimes  every 
other  day. 

August  25. — Evening.  Pulse  128.  Patient  up  and  about  the 
whole  day. 

August  28. — Evening.     Patient  somewhat  worse  ;  severe  pain 


376     ELEMENTS   OF   KELLGREN'S    MANUAL    TREATMENT 

in  the  cardiac  region  and  some  dyspnoea.  Pulse  irregular ; 
occasionally  a  few  missed  beats.  Heart  the  same  size  as  before. 
Sphygmographic  tracing  taken  after  treatment  (see  fig.  128). 

August  29. — Patient  better. 

August  30. — Patient  about  the  same. 

August  31. — Patient  about  the  same;  was  up  all  day.  Both 
sounds  reduplicated  in  the  pulmonary  area. 


Aug.  28'-  After  treatmeni: 


September  1. — Patient  better;  very  Httle  pain  in  cardiac 
region.  Sphygmographic  tracing  taken  before  the  evening 
treatment  showed  a  decided  improvement  (see  fig.  129). 

September  2. — Evening.  No  more  cardiac  pain.  Heart  still 
the  same  size ;  mitral  murmurs  as  before.  Both  sounds  in 
the  pulmonary  area  reduplicated. 


Sept.  I-  Before  treatment 


September  3. — Patient  rather  worse  again  ;  weaker,  and  in 
consequence  lay  down  during  most  of  the  day. 

September  4. — Patient  had  slept  well  for  the  first  time  since 
the  beginning  of  her  illness,  and  was  a  good  deal  stronger.  Owing 
to  unavoidable  circumstances,  the  treatment  could  only  be 
administered  once  a  day  henceforth. 

September  5. — Afternoon.  Sounds  in  the  pulmonary  area  no 
longer  reduplicated  ;  mitral  murmurs  as  before. 


HEART   DISEASES 


177 


September  6. — Patient  much  stronger ;  she  walked  about 
her  room  during  most  of  the  day.  Appetite  nearly  normal. 
Sphygmographic  tracing  taken  before  treatment  (see  fig.  130). 


Sept.  6-  Before  treatment 


September  7. — Patient's  sleep  steadily  normal.  Cardiac  dul- 
ness  less,  extending  only  slightly  to  right  of  sternum,  to  second 
rib  above  and  to  half  an  inch  within  nipple.  During  the  after- 
noon patient  walked  to  an  open-air  party  held  about  250  yards 
from  home  :  she  sat  down  and  watched  the  proceedings  from 
4  to  8  p.m.,  and  enjoyed  herself  very  much.  She  was  wheeled 
home  in  a  chair.     I  visited  her  at  9  p.m.  and  found  her  very  well. 

September  8. — Patient  up  and  about  all  day  ;  she  went  for  a 
slow  walk  of  half  an  hour. 

September  10. — Getting  stronger  every  day. 

September  11. — Morning.     Pulse  114. 

September  12. — Patient  was  able  to  come  to  my  villa  for 
treatment  (distance  about  200  yards),  and  underwent  the  move- 
ments mentioned  on  p.  379.  Pulse  before  treatment,  after 
patient  had  lain  down  quietly  for  five  minutes,  114. 


Sept.  15'-*!  Before  treatment 


September  13. — Pulse  before  treatment  112. 
September  14. — No  treatment. 

September    1-5. — Pulse    before    treatment     108.       Sphygmo- 
graphic tracing  taken  before  treatment  (see  fig.  131).     The  area 


3/8     ELEMENTS   OF   KELLGREN'S    MANUAL   TREATMENT 

in  which  the  cardiac  impulse  could  be  seen  and  felt  only  about 
two  inches  in  diameter.  Triple  mitral  murmur  and  accentuated 
second  sound  in  the  pulmonary  area.  Patient's  weight  in 
ordinary  clothes,  28  kilos. 

Pulse  rate  was  as  follows  : — 


Before 
treatment. 

After 
treatiiisnt 

September 

22       ... 

100 

96 

„ 

23       ... 

100 

96 

24       ... 

100 

92 

25       ... 

96 

96 

26 

100 

100 

27        ... 

100 

94 

28 

96 

92 

29       ... 

98 

92 

30       ... 

96 

92 

September  30. — Treatment  finished. 

October  6. — I  saw  patient  again.  She  said  that  she  felt  fairly 
strong,  and  was  able  to  walk  about  without  any  inconvenience. 
She  had  tried  to  run,  but  became  breathless.  Cardiac  impulse  in 
fourth  and  fifth  spaces  internal  to  nipple  ;  no  enlargement  to 
right  of  sternum.  Presystolic  and  systolic  murmur  in  mitral 
area,  closed  second  sound.  Accentuated  second  sound  in  the 
pulmonary  area.  Pulse  when  lying  down  94  ;  sphygmographic 
tracing  as  in  fig.  132.     Motion  daily. 


Oct.    6t-h 


-./-J 


Dr.  Harry  Kellgren  sends  me  the  following  report  on  June  17, 
1903  : — Patient  remained  in  same  condition  until  February,  1908, 
when,  according  to  the  parents,  she  had  a  similar  attack  to  the 
one  just  described.  She  got  over  it  quite  well.  Present  con- 
dition : — Patient  can  run  about  a  fair  amount  without  getting 
breathless.  The  cardiac  impulse  can  be  seen  in  the  second  to 
fifth  interspaces,  and  the  apex  beat  is  most  prominent  in  the  fifth 
interspace  slightly  external  to  the  nipple  line.  A  thrill  can  be  felt 
in  the  pulmonary  area.     On  auscultation  in  the  mitral  area  a 


HEART   DISEASES 


379 


harsh  systohc  murmur  is  heard,  propagated  into  the  axilla, 
followed  by  a  diastohc  rumbling  sound.  Both  sounds  in  the 
pulmonary  area  clear,  but  there  is  a  thrill  between  the  two  ; 
marked  accentuation  of  the  second  sound.  Aortic  and  tricuspid 
sounds  clear. 

Pulse  when  sitting  down  84  per  minute,  strong  and  regular. 
Sphygmographic  tracing,  taken  before  treatment  had  been  recom- 
menced, is  shown  in  fig.  133. 


June  17-    Before  treatment 


In  this  patient  I  observed  on  several  occasions  that  dicrotism 
of  the  pulse,  if  present,  could  be  removed  by  cervical  nerve  fric- 
tions, which  also  had  the  effect  of  reducing  the  pulse  rate  (on  one 
occasion  from  150  to  130  per  minute)  and  rendering  the  cardiac 
action  stronger.     (This  has  been  mentioned  on  p.  IG'2.) 


Treatmi-uf. 

DuyiiKj  the  acute  stage. — Heart  vibration  and  shaking,  gentle 
frictions  over  the  left  fourth  and  fifth  dorsal  nerves  near  the 
spine,  chest  vibration,  side  shaking,  making  patient  take  several 
deep  respirations  ;  stomach  exercise,  kidney  and  spleen  frictions  ; 
head  exercise,  cervical  nerve  frictions. 

From  August  22  onwards  icere  added  :  Hand  rolling,  arm 
muscle  kneading,  PP;    foot  rolling,  leg  muscle  kneading,  PP. 

From  August  2.5  omoards  were  added :  Hand  flexion  and 
extension,  AH,  foot  flexion  and  extension,  AR. 

From  August  28  onwards  were  added  :  Half  lying  leg  rolling, 
PP,  leg  flexion,  PP,  extension,  AR  ;  double  arm  rolling,  PP, 
bending  and  stretching,  AR. 

From  September  12  omoards  were  added  :  Forwards  lying  back 
exercise,  PP ;  loin  lean  stride  standing  alternate  rotation,  AR, 
ringing,  PP  ;  walk  standing  double  arm  circling,  breathing,  PA. 


CHAPTER  Yir. 

DISEASES   OF   THE  BLOOD,   LYMPHATICS,   AND 

DUCTLESS   GLANDS. 

Chlorosis. 

The  objects  of  the  manual  treatment  as  applied  to  chlorosis 
are  as  follows  : — 

(1)  To  aid  the  digestion,  which  is  usually  impaired,  and  to 
relieve  the  constipation  so  often  present. 

(2)  To  further  the  circulation  of  blood  and  lymph  by  means 
of  movements  at  joints,  and  thus  to  bring  more  nutritive  matter 
for  assimilation  and  lighten  the  work  of  the  heart. 

(3)  To  stimulate  the  nerves  of  the  body  generally. 

(4)  To  assist  and  increase  respiration,  and  thus  to  supply  more 
oxygen  to  the  body. 

All  this  will  act  on  the  constitution  as  a  whole,  and  enable  it 
to  assimilate  the  iron  that  is  brought  into  the  body  by  means  of 
the  food. 

In  case  of  great  anaemia  of  the  head,  stimulation  of  the 
abdominal  sympathetic,  by  causing  vaso-constriction  of  the 
splanchnic  area,  will  produce  compensatory  vaso-dilatation  of 
the  cerebral  arteries,  and  thus  effect  amelioration. 

Case  from  notes  taken  by  Dr.  A.  Muller  and  myself. 

G.  A.,  female,  aged  15,  domestic  servant,  came  under  the 
manual  treatment  on  November  14, 1899. 

History  of  present  illness. — During  the  autumn  of  1898,  she 
began  to  feel  weak  and  tired,  and  looked  pale.  Her  medical 
man  diagnosed  chlorosis  and  prescribed  iron.  No  improvement 
resulted.  During  the  spring  of  1899  her  condition  became  worse, 
and  she  suffered  from  headache,  breathlessness  on  slight  exertion 
and  constant  fatigue.  In  spite  of  this  she  accepted  for  pecun- 
iary reasons  a  situation  as  servant,  but  became  so  much  worse 
that  she  had  to  go  home  on  November  10,  arriving  m  a  semi- 


DISEASES  OF  THE  BLOOD,   LYMPHATICS,  &-€.  381 

collapsed  condition.  Menstruation  had  commenced  two  years 
previously,  but  had  been  irregular,  two  months  sometimes  elaps- 
ing between  the  periods ;  it  had  not  taken  place  during  the  last 
two  months. 

Exavunation. — November  14.  Patient  was  very  weak  indeed. 
The  complexion  was  markedly  greenish-yellow  ;  the  lips  very  pale. 
Even  such  slight  e.xertion  as  moving  an  arm  or  leg  was  followed 
by  breathlessness ;  and  patient  had  been  in  bed  ever  since  she 
returned  home.  There  was  a  well-defined  mitral  systolic  murmur 
and  a  hruit  de  diable.     No  cardiac  enlargement  was  present. 

After  three  days  of  treatment  at  home  patient  was  much 
better,  and  on  the  fourth  day  walked  to  my  house  for  treatment, 
a  distance  of  about  800  yards.  She  was,  however,  still  very 
feeble.  She  progressed  steadily  until  November  27,  when  a  slight 
relapse  occurred  ;  she  was  treated  at  home  during  that  day.  On 
the  '28th  she  was  again  able  to  come  to  me  for  treatment.  Her 
headache  left  her,  her  colour  become  normal,  she  grew  strong, 
and  her  menstruation  returned  normal  in  amount  and  regular. 
On  January  18,  1900,  she  was  quite  restored  and  capable  of 
active  work.      Treatment  finished. 

During  March  she  got  a  temporary  situation  as  nurse.  During 
January,  1901,  she  went  into  a  laundry,  and  worked  there 
steadily  until  July,  1902,  when  I  agaui  saw  her  ;  she  then  said 
that  she  was  in  splendid  health. 

Treatment. 

This  at  first  consisted  chiefly  of  a  few  passive  movements, 
including  stomach  exercise.  Other  exercises  were  gradually 
added,  and  finally  the  gymnastic  prescription  was  as  follows  : — 

(1)  Half  lying  double  arm  rolling,  PP,  bending  and  stretch- 
ing, AE. 

(2)  Stretch  half  lying  running  nerve  frictions,  PP,  side 
shaking,  PP. 

(3)  Heave  grasp  standing  chest  clapping,  side  shaking,  PP. 

(4)  Half  lying  double  foot  rolling,  PP,  flexion  and  exten- 
sion, AR. 

(5)  Stretch  grasp  standing  drawing  forwards,  PP,  kidney 
frictions,  PP. 

(6)     Forwards  lying  back  exercise,  PP. 


382     ELEMENTS   OF   KELLGHEN'S   MANUAL    TREATMENT 

(7)  Stretch  stride  standing  bending  forwards,  PA. 

(8)  Sitting  trunk  extension  and  flexion,  PA. 

(9)  Half  lying  leg  rolling,  PP,  flexion,  PA,  extension,  AE. 
(10)  Half  lying  stomach  exercise,  PP. 

Lymphangitis. 

Under  this  heading  will  be  considered  the  treatment  of  blood 
poisoning  in  consequence  of  infection  from  wounds,  abrasions  of 
the  skin,  &c. 

The  manual  treatment  is  applied  as  follows : — 

Locally,  running  vibrations  and  frictions,  &c.,  are  admin- 
istered centrifugallij  down  to  the  infected  focus  in  order  to 
prevent  the  condition  spreading  upwards,  and  to  endeavour  to 
cause  the  infective  products,  if  possible,  to  pass  back  the  way 
they  came.  (To  appl}^  such  manipulation  centripetally,  i.e.,  in 
the  direction  of  the  venous  and  lymph  flow,  would,  of  course, 
only  result  in  great  aggravation  of  the  condition,  see  pp.  20.5,  &c.) 
Constitutionally,  exercises  are  prescribed  to  improve  the  con- 
dition of  the  body  as  a  whole,  and  to  promote  elimination  of  the 
toxins  that  have  already  been  absorbed. 

I  append  details  of  five  cases  treated  by  the  above  method  ; 
no  antiseptics  were  used. 

Case  1. 

E.  L.,  female,  aged  13f  years,  canie  under  the  manual  treat- 
ment on  April  15,  1900. 

History  of  present  condition. — During  the  whole  winter 
patient  had  had  a  sore  place  in  the  right  foot  on  the  anterior 
surface  of  the  first  metatarsal  bone  at  its  distal  end,  caused  by 
wearing  tight  shoes.  Pain  was  felt  in  this  area  during  the 
evening  of  April  13.  During  the  following  night  patient  slept 
badly,  'and  the  pain  got  worse  during  the  ensuing  day.  At 
6  p.m.  on  April  15  I  was  called  in. 

Examination. — Patient  complained  of  great  pain  in  the  right 
big  toe  and  over  various  points  on  the  inside  of  the  right  calf. 
There  was  continual  pain  in  the  lower  leg,  even  when  keeping 
the  foot  and  leg  still.  Patient  could  only  set  her  foot  on  the 
ground  on  its  outer  edge  ;  she  could  not  place  it  flat  on  the 
ground  on  account  of  the -pain.     Walking  was  almost  impossible. 


DISEASES  OF  THE  BLOOD,  LYMPHATICS,  &c. 


383 


There  was  an  abscess,  in  which  fluctuation  could  be  detected,  on 
the  right  great  toe  at  the  distal  end  of  the  first  metatarsal ; 
around  the  abscess  there  was  a  red  swollen  area,  extending  right 
across  the  foot  over  the  distal  half  of  the  whole  metatarsus;  similar 
areas  were  visible  along  the  inner  side  of  the  calf,  as  in  fig.  134  (the 
dotted  part  shows  their  extent).  The  entire  foot  was  swollen, 
all  the  swollen  parts  being  very  tender.  The  inguinal  glands 
were  enlarged.     There  was  fever.     The  pulse  was  92. 


Treatment. — Suction  vibrations  round  the  abscess,  causing  the 
extrusion  of  a  little  pus  and  serum  ;  centrifugal  running  vibra- 
tions along  the  inflamed  area  down  to  the  abscess.  Vibrations 
over  the  inguinal  glands  ;  stomach  exercise.  Kesult :  no  pain 
when  foot  was  kept  still  ;  patient  able  to  walk  much  better  and 
with  less  pain,  even  on  the  whole  foot.  General  condition 
improved. 

April  16. — Morning.  Patient  had  slept  ve-y  well  during  the 
night.  Hardly  any  pain  in  foot,  and  patient  said  she  felt  as  if 
nothing  were  the  matter  with   it.     Swelling  of  foot  gone  ;  in- 


384     ELEMENTS    Of    KELLGREN'S    MANUAL   TREATMENT 

tlaiumation  and  redness  much  better.  Treatment  ;  a  slight 
amount  of  pus  was  expressed  from  the  abscess.  After  treatment 
pulse  72.  Evening.  No  pain  at  all,  not  even  on  walking.  No 
tenderness  on  pressure  excepting  over  the  tibialis  anticus 
tendon.  No  redness  along  inner  side  of  the  calf.  Abscess 
rapidly  healing    up.     Treatment. 

April  17. — Patient  had  slept  very  well.  No  pain.  Inflam- 
mation and  redness  gone.     Treatment  once. 

April  18. — Foot  and  leg  perfectly  normal,  excepting  for  the 
wound  on  the  big  toe,  which  showed  some  scabs  on  it.  Patient 
able  to  wear  boot  as  usual.     Treatment  for  the  last  time. 

April  19. — Patient  went  to  school,  it  being  the  first  day  of  the 
term. 

April,  190'2. — Foot  had  been  quite  well  during  the  two  years 
which  had  elapsed. 

Case  2. 

P.  A.,  male,  aged  9,  came  under  the  manual  treatment  on 
April  2,  1900. 

History  of  present  condition. — Patient  bad  hurt  his  left  wrist 
about  four  days  previously  ;  he  did  not  remember  how.  Swelling 
over  the  joint  resulted  and  during  the  evening  of  April  1  he 
complained  of  stiffness  in  the  shoulder-joint.  On  April  2  his 
mother  noticed  red  lines  on  his  forearm  ;  patient  was  brought 
to  me  at  7  a.m. 

Examination.- — Two  small  abscesses  near  the  wrist,  out  of 
which  the  mother  had  during  the  same  morning  squeezed  some 
pus.  Large  red  lines  marking  swollen  lymph  vessels  along  front 
and  external  surface  of  forearm  and  inner  surface  of  upper  arm. 
Swollen  glands  in  the  axilla.  Pain  on  pressure  at  the  spots  men- 
tioned at  the  wrist,  and  on  moving  the  shoulder-joint ;  otherwise 
no  pain.     Fever. 

Treatment. — Centrifugal  running  vibrations  and  frictions  from 
upper  arm  towards  wrist ;  some  serum  exuded  from  the  abscess 
cavities  in  consequence.  Stomach  exercise,  &c.  Patient  said  he 
felt  better  in  consequence  of  the  treatment.  Similar  treatment  at 
11.30  a.m.  ;  patient  again  sensible  of  improvement.  Treatment 
at  5  p.m. ;  patient  better;  less  pain  in  axilla  ;   no  fever. 

April  3. — Morning.     Patient  much  better;  treatment.     Even- 


DISEASES  OF  THE  BLOOD,  LYMPHATICS,   S-c.  385 

ing.  Lymphangitis  bad  disappeared.  No  pain  in  axilla.  Affected 
areas  near  wrist  much  less  red  ;  one  of  them  almost  gone,  with  a 
little  scab  remaining.     Treatment. 

April  4. — Affected  areas  at  wrist  practically  normal.  Arm 
normal.     Treatment  for  the  last  time. 

September,  1902. — Patient  quite  well. 

Case  'S. 

A.  L.,  female,  aged  9,  came  under  the  manual  treatment  on 
November  6,  1900. 

History  of  jyrexent  condition. — Patient  hurt  her  right  thenar 
eminence    about    November   4   (date    not    quite    certain).       On 


November  6  patient  noticed  that  the  spot  where  she  bad  hurt 
herself  was  tender  and  red,  and  she  came  to  see  me  about  it. 

Examination. — There  was  an  inflamed  area  over  the  base  of 
the  thumb,  with  a  small  abscess  in  the  middle  (at  A  in  fig.  18.5). 
Along  the  front  of  the  forearm  was  a  red  line,  which  opened  into 
the  median  basilic  vein  at  the  elbow  (B).  Internal  to  this  was 
some  redness,  which  extended  over  the  lower  half  of  the  fore- 
arm (C).  The  glands  in  the  axilla  were  swollen.  Temperature 
101°,  pulse  135. 

Treatment. —  Locally,    centrifugal    running    vibrations,    &c., 
causing  the  pus  from  the  abscess    to   be    expressed.     Constitu- 
tional treatment  was  also  administered. 
25 


386      ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

November  7. — No  red  lines,  no  fever ;  pulse  120.  Treatment 
as  before. 

November  8. — No  swollen  glands  in  axilla. 

November  9  to  14. — A  few  centrifugal  vibrations  were  adminis- 
tered every  day. 

November  16. — No  more  pus.  Wound  healed  up.  Patienl 
normal. 

October,  190-2.— Patient  quite  well. 

Case  4. 

D.  A.,  male,  aged  11,  came  under  the  manual  treatment  on 
November  4,  1900. 

History  of  ]] resent  condition. — Patient  was  bitten  in  his  left 
hand  by  a  rabbit  on  November  1.  On  November  4  the  bitten 
place  was  painful,  and  there  was  also  pain  in  the  axilla  ;  patient 
v?as  brought  to  me. 

Examination. — There  was  a  wound  about  half  an  inch  long 
with  a  scab  on  it,  discharging  pus,  situated  over  the  fifth 
metacarpal  bone.  One  or  two  red  lines  marking  out  inflamed 
lymph  vessels  were  visible  on  the  forearm.  The  whole  of  the 
forearm  on  the  ulnar  side  was  very  tender  to  pressure.  There 
were  enlarged  glands  in  the  axilla. 

Treatment  on  the  usual  principles.  By  its  means  some  pus 
was  expressed. 

November  5. — Less  pain  in  the  axilla.  Red  lines  gone. 
Some  more  pus  was  expressed. 

November  6. — Glands  in  axilla  could  no  longer  be  felt.  Very 
little  tenderness  on  pressure  in  forearm.  Some  pus  could  still  l)e 
expressed  from  the  wound. 

November  7  to  13. — Centrifugal  vibrations  were  executed  for 
two  minutes  once  a  day. 

November  13. — Wound  healed  up.  No  more  pus.  Patient 
cured.     Treatment  finished. 

July,  1902. — Patient  quite  well. 

Case  o. 

J.  S.,  aged  26,  workman  in  Huskvarna  factory,  came  under 
the  manual  treatment  on  February  14,  1902. 


DISEASES  OF  THE  BLOOD,  LYMPHATICS,  A-c.  387 

History  of  present  condition. — Patient  had  hurt  his  left  hand 
over  the  metacarpo-phalaugeal  joint  of  the  forefinger  about  a 
month  previously  by  catching  it  in  some  machinery.  The  wound 
healed  fairly  well,  but  there  was  slight  watery  discharge  until 
February  13,  1902.  Patient  slept  badly,  and  on  waking  up 
suffered  a  good  deal  of  pain  in  the  sore  place  (which  was  again 
inflaming),  and  also  in  the  forearm  ;  his  forefinger  was  stiff,  and 
there  was  pain  on  moving  it.  During  the  afternoon  of  the  same 
day  he  experienced  more  pain  and  more  stiffness,  and  the  inflam- 
mation was  worse  ;  the  elbow  and  shoulder-joints  had  also 
begun  to  hurt.  He  slept  very  little,  and  had  fever  during  the 
night.     He  came  to  me  during  the  evening  of  February  14. 

Exaynination. — The  original  wound  was  much  inflamed;  it  was 
about  the  size  of  a  sixpence,  with  red  lines  leading  from  it  along 
the  outer  side  of  the  forearm  and  inner  edge  of  the  biceps  in  the 
upper  arm.  An  enlarged  gland  could  be  felt  just  above  the 
elbow  on  its  inner  side,  and  several  others  along  the  inner  edge  of 
the  biceps  and  in  the  axilla.     Temperature  101°,  pulse  128. 

Treatment  on  the  usual  principles.  By  it  some  pus  was 
expressed,  and  the  patient  felt  better  after  it. 

February  15. — Patient  had  slept  very  well.  No  pain  in 
wound.  Less  redness  of  forearm.  Pain  in  axilla  only  on  lifting 
arm.  Enlarged  lymphatic  glands  smaller.  Temperature  98'8', 
pulse  80.     Treatment  twice. 

February  16. — Morning.  No  redness  of  forearm,  glands 
smaller.  A  drop  of  pus  was  all  that  could  be  obtained  from  the 
wound. 

Evening.  Glands  not  palpable  any  longer.  Wound  healing 
up  very  well.     Treatment  for  the  last  time. 

October,  1902. — -Patient  still  keeping  quite  well. 

Exophthalmic  Goitre. 

Miss  S.,  aged  28,  came  under  the  manual  treatment  on 
March  7,  1902. 

History  of  present  illness. — Patient  was  under  Mr.  Kellgren's 
treatment  for  enlarged  thyroid  in  1S90  ;  the  treatment  lasted 
two  months,  and  patient  left  cured.  Since  then  she  had 
been  in  good  health  until  1900.  She  was  confirmed  during  the 
summer  of  that  year,  and  had  since  been  tormented  by  religious 


3S8     ELEMENTS   OF   KELLGREN'S   MANUAL    TREATMENT 

doubts  and  fears  and  had  become  ver)^  emotional.  The  severe 
symptoms  dated  from  December  31,  1901.  Since  that  day  she 
had  been  extremely  nervous,  irritable,  and  despondent,  and  able 
to  sleep  only  an  hour  or  two  at  the  most  in  the  night ;  she  was 
easily  thrown  into  tears.  She  consulted  a  medical  man  during 
January  ;  he  diagnosed  neurasthenia  and  prescribed  bromides. 
However,  she  became  steadily  worse. 

Examination. —  Exophthalmos  was  well  marked,  and  the 
palpebral  aperture  wide,  the  sclerotic  being  visible  above  and 
below  the  cornea.  Patient  winked  continually,  and  was  unable 
to  keep  her  eyes  still.  On  looking  upwards  the  forehead  did  not 
wrinkle,  and  on  looking  downwards  the  upper  lid  did  not  follow 
the  eyeball.  Both  pupils  were  dilated,  and  reacted  only  slightly 
to  light  and  accommodation.  The  tension  was  +  in  both  eyes, 
and  on  ophthalmoscopic  examination  there  was  pulsation  in  the 
retinal  arteries  and  cupping  of  the  discs.  There  was  great  tender- 
ness to  pressure  over  the  supraorbital  nerves  and  anterior  part  of 
the  temporal  fossae.  There  was  a  continued  sense  of  fulness  in 
the  throat ;  the  thyroid  gland  was  considerably  enlarged,  forming  a 
tumour  about  3  inches  from  above  downward,  causing  both  sterno- 
mastoids  to  bulge  outwards.  The  tumour  did  not  extend  down 
as  far  as  the  sternum,  and  the  enlargement  was  equal  on  both 
sides.     No  pulsation  was  visible,  but  it  could  be  felt  in  the  gland. 

There  were  fine  tremors  in  the  arms  on  holding  them  out  ; 
the  handwriting  was  very  shaky  indeed.  There  was  great  weak- 
ness of  all  the  muscles  ;  patient  could  hardly  offer  any  resistance 
m  her  duplicate  movements,  and  fine  tremors  of  the  whole  body 
took  place  when  performing  them.  Her  appetite  was  poor  ;  she 
did  not  suffer  from  vomiting,  but  was  subject  to  a  good  deal  of 
eructations.  She  was  constipated,  but  able  to  obtain  a  motion 
every  other  day  by  drinking  Carlsbad  water.  There  was  great 
tenderness  over  the  spleen,  liver,  kidneys,  ovaries  and  spinal 
nerves.  Patient  was  troubled  with  a  feeling  of  throbbing  in  the 
arteries,  especially  in  the  head.  The  second  sound  in  the  aortic 
area  was  accentuated  ;  there  were  no  murmurs.  The  pulse  after 
lying  down  for  ten  minutes  was  110  per  minute. 

Patient  suffered  very  much  from  headache,  sleeplessness, 
irritability  and  despondency ;  and  cried  easily.  Babinsky's  sign 
was  not  present  ;  tendo  Achillis  jerk  was  present,  two  or  three 
jerks  were  felt  on  trying  for  ankle  clonus ;  the  patellar  reflexes 
were  greatly  exaggerated. 


DISEASES  OF  THE  BLOOD,  LYMPHATICS,  &-€.  7,Sc) 

The  urine  contained  a  little  sugar,  as  tested  by  Fehliug's 
solution,  but  no  albumen.  Patient  had  become  much  thinner  of 
late  ;  her  present  weight  was  o3"2  kilos. 

Treatment. 

(1)  Sitting  head  exercise,  PP ;  suction  vibrations  on  the 
thyroid  gland,  PP  ;  double  supraorbital  nerve  vibrations  and 
frictions,  PP. 

(2)  Reach  grasp  standing  head  flexion,  PR,  extension,  AR ; 
cervical  nerve  frictions,  PP. 

(3)  Sitting  double  elbow  pressing  downwards,  PR,  up- 
wards, AR. 

(4)  Forwards  lying  back  exercise,  PP. 

(5)  Side  span  standing  drawing  sideways,  PP,  spleen  and 
kidney  frictions,  PP. 

(6)  Sitting  trunk  extension  and  flexion,  PA ;  sit  lying  knee 
extension  and  flexion,  PP,  extension,  AR,  flexion,  PR. 

(7)  Heave  grasp  standing  side  shaking,  PP,  heart  vibration,  PP. 

(8)  Ride  sitting  trunk  flexion,  PR,  extension,  AR. 

(9)  Half  lying  stomach  exercise,  PP,  ovary  vibration,  PP. 
Progress. — March  8. — Patient  slept  better  during  the  night. 
March  10. — Patient  slept  badly  again. 

March  1.3. — Patient  slept  better  than  she  had  done  for 
months.     Sense  of  fulness  in  the  throat  gone. 

March  1.5. — Less  tenderness  over  the  supraorbital  nei"ves. 

March  22. — Patient  slept  very  well  every  other  night  ;  was 
much  stronger  and  able  to  offer  a  good  deal  of  resistance  during 
duplicate  movements.  Less  tenderness  over  spleen,  kidneys, 
liver,  ovaries  and  spinal  nerves. 

March  2-4. — Weight  .54-5  kilos.  Pulse  after  lying  down  for 
ten  minutes  was  100  per  minute. 

March  26. — Eyes  not  so  prominent,  pupils  less  dilated ; 
patient  wrinkled  her  forehead  slightly  when  looking  up,  and  the 
eyelid  followed  eye  downwards.     Tension  normal  in  both  eyes. 

March  27. — Patient  slept  fairly  well  four  nights  running. 

April  .3. — Thyroid  smaller.  Less  nervous.  Tendo  Achillis  jerk 
present.  No  jerks  in  trying  for  ankle  clonus  ;  patellar  reflex  not 
so  exaggerated.     No  glycosuria. 

April  .5. — Treatment  interrupted  until  April  15.     Eyes  reacted 


.390   ELEMENTS   OF   KELLGREN'S   MANUAL    TREATMENT 

nonuall}'  to  light  and  accommodation  ;  no  pulsation  in  the  retinal 
vessels,  but  cupping  of  the  discs  still  present.  Some  exophthal- 
mos was  the  only  abnormal  eye  symptom  present.  Less  tender- 
ness over  the  supraorbital  nerves.  Thyroid  much  smaller  ;  very 
little  bulging  of  the  sterno-mastoids.  Fine  tremors  only  in 
hands.  Patient  stronger,  she  had  taken  several  three  mile  walks 
lately.  Appetite  normal,  bowels  acting  daily.  No  throbbing  of 
the  arteries.  Accentuated  second  sound  in  the  aortic  area  still 
present.  Pulse  after  lying  down  for  ten  minutes  88  per  minute. 
Tenderness  absent  over  the  spleen  and  liver  but  still  present  over 
the  kidneys  and  lower  dorsal  nerves  ;  hardly  any  tenderness  over 
the  ovaries.  Patient  sleeping  very  well.  Reflexes  the  same  as 
on  April  3.     No  glycosuria. 

Patient  returned  to  treatment  on  April  15,  having  been  to 
stay  with  some  friends,  who  were  astonished  at  the  improvement 
she  had  made  since  they  last  saw  her,  which  was  in  the  middle  of 
February.  She  had  slept  very  well  every  night  since  her  depar- 
ture excepting  the  last  night.  Her  condition  was  about  the  same 
as  on  April  5.     No  glycosuria. 

May  17. — Treatment  finished.  Patient's  general  condition 
very  good.  Slight  exophthalmos  still  present ;  she  winked  much 
less  than  before,  and  could  keep  her  eyes  much  more  still.  Her 
forehead  wrinkled  on  looking  up  ;  on  looking  downwards  the 
lapper  lid  followed  the  eyeball.  The  pupils  reacted  normally  to 
light,  although  sluggishly  to  accommodation.  The  tension  oi  the 
eyes  was  normal ;  there  was  no  pulsation  of  the  retinal  vessels. 
The  thyroid  gland  was  smaller,  but  could  still  be  plainly  felt. 
The  sterno-mastoids  hardly  bulged  at  all.  All  the  muscles  were 
stronger ;  there  were  hardly  any  fine  tremors  of  the  hands  on 
holding  them  out,  and  none  in  any  other  part  of  the  body,  not 
even  during  strong  duplicate  movements.  The  handwriting 
was  normal.  Normal  motion  every  other  day.  Appetite  good. 
No  tenderness  over  liver,  kidneys,  ovaries,  or  spinal  nerves. 

No  accentuation  of  second  sound  in  the  aortic  area.  No 
throbbing  in  the  arteries ;  cardiac  action  much  quieter,  the 
pulse  after  lying  down  for  ten  minutes  was  70  per  minute. 

Sleep  very  good  ;  despondency  gone  ;  irritability  gone.  No 
tendo  Achillis  jerk  or  ankle  clonus  jerks  present.  Knee-jerks 
well  marked.     No  glycosuria.     Weight  55  kilos. 

I  saw  patient  again  on  August  9  of  the  same  year.  She  said 
she  was  feeling  very  well  and  had  grown  fatter  of  late. 


CHAPTER    VIIT. 

DISEASES    OF  THE   NERVOUS   SYSTEM. 

These  are  conveniently  considered  under  the  following 
heads : — 

I. — Organic  brain  and  spinal  cord  diseases,  whether  depen- 
dent on  a  sudden  lesion  such  as  inflammation  or  haemorrhage,  or 
slowly  progressive  such  as  sclerosis. 

II. — Peripheral  nerve  diseases  such  as  diphtheritic  paralysis, 
neuritis,  &c. 

III. — Functional  nervous  diseases. 

IV. — Sympathetic  nerve  diseases. 

I. — Organic  Brain  and  Spinal  Cord   Diseases. 

Want  of  space  compels  me  to  consider  only  the  treatment 
of  the  chronic  stage  of  the  above  diseases. 

The  object  of  the  treatment  is  to  restore  the  normal  vital 
activity  to  the  primarily  degenerated  nerve-cells  and  nerve-fibres, 
and  to  the  secondarily  affected  muscles,  &c. 

The  following  movements  are  employed  : — 

(1)  Manipulations  which  stimulate  the  central  nervous  system 
directly,  especially  nerve  frictions,  local  and  general.  The 
affected  motor  nerves  are  treated  by  means  of  nerve  frictions, 
stationary  or  riinning,  hackings,  &c.  The  affected  sensory  nerves 
are  treated  by  means  of  nerve  frictions,  stationary  or  running, 
clappings,  &c.  The  spinal  cord  is  treated  by  means  of  peripheral 
nerve  stimulation  as  just  mentioned,  hackings  over  it,  strong 
vibration  over  any  affected  segments.  Sec.  The  brain  is  treated 
by  means  of  a  short,  sharp  head  exercise,  with  particular  atten- 
tion to  any  specially  affected  area.  The  cerebro-spinal  system  as 
a  whole  is  treated  by  means  of  running  nerve  frictions  from  head 
to  foot,  &c. 


392     ELEMENTS  OF  KELLGREN'S   MANUAL    TREATMENT 

(2)  Passive  inauipulatioiis  on  any  weakened  or  paralysed 
muscles. 

First  and  foremost,  nerve  frictions  on  the  motor  nerves 
leading  to  the  muscles,  as  already  inentioned. 

Secondarily,  passive  flexions,  extensions,  rollings,  &c.  For 
atrophic  conditions  these  are  administered  energetically  through 
the  largest  radius  in  order  to  cause  :  Promotion  of  the  circulation 
of  the  hlood,  and  subsequently  a  vaso-dilatation  in  the  part 
exercised,  and  promotion  of  the  circulation  of  the  lymph  with 
increased  production  thereof.  Stimulation  of  the  nerves  and 
muscles  from  alternate  elongation  and  shortening  and  from  the 
reinforcement  of  the  reflex  arc  through  shortening  of  the  antagon- 
istic muscles.  For  spastic  conditions  where  there  is  no  atrophy 
beyond  the  atrophy  of  disuse,  passive  movements  at  joints  are 
administered  in  a  different  manner.  They  are  executed  fairly 
slowly ;  as  soon  as  spasm  arises  the  movement  is  wholly  or 
partially  stopped,  and  an  endeavour  made  to  overcome  the  spasm 
by  gently  elongating  or  shortening  the  muscle  or  muscles  in  which 
the  spasm  has  arisen.  When  it  has  been  overcome  the  move- 
ment is  again  continued.  There  is  also  a  psychical  encouraging 
effect ;  the  movement  executed  is  one  which  perhaps  the  patient 
himself  has  been  unable  to  achieve  for  years  past  and  of  whicli 
he  has  forgotten  the  sensation.  He  is  thus  encouraged  to  attempt 
its  repetition. 

Thirdly,  kneadings  of  any  affected  muscles.  In  atrophic 
conditions  these  have  a  certain  amount  of  stimulatory  effect,  but 
by  no  means  so  marked  a  one  as  stimulatory  manipulations 
on  the  nerves  supplying  these  muscles.  It  must  be  remembered 
that  the  atrophy  is  practically  always  secondary  to  the  nerve 
degeneration,  and  that,  therefore,  stimulating  the  muscles  directly 
by  kneadings,  &c.,  cannot  have  the  same  effect  as  stimulating 
the  nerves  directly  b)'  frictions. 

(3)  Active  movements,  purely  active  or  duplicate,  during 
which  the  patient  has  to  try  his  utmost  (within  the  physiological 
limit)  to  move  any  paralysed  muscles  or  ataxic  limbs,  i.e.,  the 
patient  has  to  try  his  utmost  to  restore  the  continuity  in  the 
interrupted  motor  or  sensory  paths.  Such  voluntary  efforts 
excite  the  nerve-cells  to  increased  activity,  and  aid  in  the 
restoration  of  the  degenerated  nerve-fibres  ;  each  renewed 
effort   of   the   will  sends  down   a  fresh  nervous   impulse  which 


DISEASES  OF  THE  NERVOUS  SYSTEM  393 

tends  to  overcome  any  obstruction.  Such  movements  also  train 
ordinarj'  sensation'  and  the  sense  of  coordination  and  inhibition. 

By  means  of  various  fixations  of  the  Hmb  all  other  muscles 
may  be  placed  at  rest  except  those  it  is  desired  to  exercise,  on 
which  the  patient  is  thus  enabled  to  concentrate  all  his  enerj^y. 

(4)  Manipulations  to  improve  the  general  condition  of  the 
patient,  e.g.,  to  better  the  circulation  and  promote  the  activity  of 
the  assimilative  and  digestive  organs.  Special  attention  should 
be  paid  to  any  secondarily  affected  organs,  such  as  heart, 
bladder,  &c. 

It  is  advisable  to  refer  here  to  some  points  in  the  technique  of 
the  application  of  active  movements  to  cases  of  paralysis.  For 
purposes  of  illustration  it  is  convenient  to  take  a  case  where,  in 
consequence  of  the  anterior  tibial  muscles  being  affected,  the 
patient  states  that  he  is  unable  to  bend  his  foot  by  himself.  It 
does  not,  however,  follow  in  consequence  of  his  statement  that 
there  is  no  voluntary  muscle  power  in  the  anterior  tibial  muscles  ; 
it  is  necessary  to  test  further,  as  follows  : 

(a)  The  patient  is  exhorted  to  try  his  utmost  to  bend  his  foot ; 
after  a  few  seconds,  or  perhaps  even  only  after  a  minute,  a  very 
slight  amount  of  movement  may  manifest  itself.  This  arises 
from  summation  of  voluntary  stimuli. 

(b)  The  patient's  ankle-joint  is  flexed  as  far  as  it  will  go,  and 
the  patient  then  asked  to  resist  his  utmost  while  the  reverse 
movement  is  executed.  Some  resistance  may  be  felt  (see 
pp.  37,  38). 

(c)  The  patient's  ankle-joint  is  slowly  flexed,  the  patient  being 
requested  to  assist  as  much  as  possible.  Some  assistance  may  be 
felt  (see  p.  13). 

In  some  cases,  even  if  the  results  are  negative,  voluntary 
power  can  sometimes  be  elicited  after  executing  strong  nerve 
frictions  on  the  anterior  tibial  nerve  followed  by  an  energetic  foot 
rolling  given  through  the  largest  radius. 

It  is  often  useful  to  eliminate  the  action  of  gravity,  i.e., 
supposing  a  patient  unable  to  abduct  his  right  leg  in  left  side 
lying  position,  he  may  yet  be  able  to  do  so  in  half  lying  position, 
and  so  on. 

The  golden  rule  for  treatment  of  paralysis  is  :   Try  and  teach 

'  Cf.  "  Optic  .\trophy  aud  Tabes  Dorsalis,''  by  the  author,  in  Lancet,  June  '^'J, 
1901,  p.  1861. 


j94     ELEMENTS  OF   KELLGREN'S    MANUAL    TREATMENT 

the  patient  to  regain  the  voluntary  power  of  those   movements 
which  he  has  lost  in  consequence  of  the  nervous  lesion. 

The  treatment  of  crises  such  as  occur  in  locomotor  ataxia. — 
Special  exercises  should  be  administered  for  the  benefit  of  the 
part  affected  dui'ing  the  crises,  i.e.,  during  gastric  crises  exercises 
chiefly  for  the  stomach  and  abdomen  should  be  administered, 
and  so  on.  During  one  case  of  locomotor  ataxia  of  eight  years' 
standing  that  I  treated  in  October — November,  1900,  there 
occurred  two  gastric  crises  with  fever ;  the  treatment  (twice  a 
day)  was  as  follows  :  stomach  vibration,  frictions  on  the  left 
sixth,  seventh,  and  eighth  dorsal  nerves  near  the  spine,  stomach 
exercise  ;  general  treatment  for  fever.  The  improvement  in  the 
patient's  condition,  which  otherwise  proceeded  slowly,  was 
marked  for  the  two  days  immediately  following  each  crisis.  This 
tends  to  show  that  in  some  cases  such  crises  can  act  as  general 
eliminators,  and  that  they  might  therefore  be  regarded  as  an 
effort  of  Nature  towards  attempting  a  cure. 


II. — Peripheral   Nerve  Diseases. 

(1)  Neuritis  (excluding  neuralgia).  Is  treated  in  very  much 
the  same  way  as  atrophic  spinal  paralysis. 

(2)  Neuralgia.  Is  treated  by  means  of  sedative  manipulations, 
such  as  vibrations  over  the  painful  nerves ;  gentle  passive  move- 
ments at  joints  can  be  added  where  this  is  possible.  As  improve- 
ment sets  in,  frictions  on  the  painful  nerves  are  made  use  of; 
more  energetic  passive  movements,  duplicate  movements,  &c., 
can  be  added  when  possible. 

(8)  Spasm  of  muscles  from  nervous  causes.  Is  treated  by 
means  of  stimulatory  manipulations  on  the  nerve,  and  by 
exercises  to  strengthen  the  antagonistic  muscles  (see  p.  75). 

III. — Functional    Nervous   Diseases. 

It  is  impossible  to  lay  down  any  general  directions  for  the 
treatment  of  these ;  each  case  has  to  be  taken  on  its  own  merits. 

IV.— Sympathetic  Nervous  Diseases. 

These  conditions  ai'e  not  ordinarily  accorded  a  place  in  text- 
books.    It  is,  however,  often  found  while  examining  a  patient, 


DISEASES  OF  THE  NERVOUS   SYSTEM  395 

say,  for  dyspepsia,  that  there  is  greatly  diminished  sensation 
in  the  abdominal  prevertebral  plexuses,  or  that  no  radiating 
sensation  is  experienced  on  executing  a  friction  on  the  umbilicus, 
L^c.  This  leads  to  a  diagnosis  of  deficient  functionability  in  the 
sympathetic  nerves  of  the  part,  although  it  is  generally  very 
difficult  indeed  to  say  whether  this  sympathetic  condition  is 
primary  or  secondary. 

It  is,  however,  impossible  to  give  a  comprehensive  account  of 
the  subject,  or  to  lay  down  general  directions  for  treatment ; 
each  case  must  be  taken  on  its  own  merits. 

I  wish  especially  to  emphasise  the  fact  that  the  manual 
treatment  should  be  given  a  trial  as  early  as  possible  in  cases 
of  organic  disease  of  the  central  nervous  system,  because  experi- 
ence has  shown,  particularly  in  slow  degenerative  processes  such 
as  sclerosis,  &c.,  that  very  little  improvement  can  be  expected  in 
most  cases  from  the  administration  of  drugs  and  electricity. 
Cases  treated  by  such  methods  without  improvement  are  usually 
difficult  to  benefit  by  the  manual  treatment ;  cases  treated 
l)y  such  methods  with  improvement  generally  improve  faster 
when  the  manual  treatment  is  substituted.  Cases  which  have 
never  received  any  treatment,  even  if  of  many  years'  stand- 
ing, are  often  more  easy  to  benefit  by  means  of  the  manual 
treatment  than  correspondingly  recent  cases  which  have  not 
improved  under  ordinary  medicinal  or  electrical  treatment.  I 
have  also  had  some  opportunities  of  observing  that  cases  which 
have  improved  by  means  of  the  manual  treatment,  and  which 
have  then  for  various  reasons  been  removed  from  its  influence 
and  brought  under  that  of  drugs  and  electricity,  nearly  always 
either  remain  stationary  or,  in  sclerosed  conditions,  become 
worse  again ;  whereas  cases  which  have  improved  by  means  of 
the  manual  treatment  sometimes  continue  to  do  so  after  the 
treatment  has  been  stopped,  provided  that  none  other  be  made 
use  of. 

I  append  a  list  of  all  the  nervous  cases  I  have  been  able 
to  watch  carefully,  and  in  which  there  has  been  no  doubt  in  my 
mind  as  to  the  diagnosis.  By  "  cured  "  I  mean  that  the  patient 
was  freed  from  all  abnormal  nervous  symptoms,  and  that  such 
cases  were  under  observation  at  least  one  year,  in  many  cases 
up  to  four  years,  from  the  date  at  which  the  manual  treatment 


3q6     elements  OE  KELLCREN'S   MANUAL    TREATMENT: 

was  concluded,  and  that  diu-ing  that  time  no  return  of  any 
abnormal  nervous  symptom  took  place. 

In  all  the  other  cases  mentioned  excepting  two  (see  p.  397) 
improvement  resulted  from  the  treatment. 

Neuritis  and  neuralgia. — Sciatica,  seven  cases ;  three  cured. 
Tic  douloureu.K,  one  case,  lietrobulbar  haemorrhage  with  optic 
atrophy,  one  case.  Other  neuritis,  eight  cases.  Other  neuralgias, 
ten  cases  ;    five  cured. 

Post-diphtheritic  paralysis,  two  cases  ;  one  cured. 

Convulsive  tic,  one  case  ;  cured. 

Facial  nerve  paralysis. — Peripheral,  two  cases  ;  one  cured. 
Central,  one  case. 

Congenital  fsaralysis  of  brachial  plexus,  one  case ;  cured. 

Gunshot  paralysis  of  ulnar  and  median  nerves,  one  case. 

Spinal  transverse  myelitis,  one  case. 

Apoplexy  of  the  spinal  cord,  two  cases ;  one  cured. 

Infantile  paralysis,  eighteen  cases  ;     two  cured. 

Spastic  paraplegia,  seven  cases. 

Locomotor  ataxia,  eight  cases  ;  two  cured. 

Compression  of  the  spinal  cord  from  scoliosis,  one  case. 

Tertiary  cerebro-spinal  syphilis,  one  case. 

Amyotrophic  lateral  sclerosis,  one  case. 

Gunshot  wound  of  spine  at  level  of  fifth  dorsal  vertebra,  one 
case. 

Bulbar  paralysis,  three  cases. 

Sequelae  of  secondary  syphilitic  meningitis,  one  case. 

Hyperaemia  of  the  brain,  four  cases  ;  three  cured. 

Cerebral  haemorrhage  and  embolism,  six  cases;  one  cured. 

Cerebral  subdural  htemorrhage,  one  case. 

Infantile  spastic  diplegia,  two  cases. 

Disseminated  cerebro-spinal  sclerosis,  three  cases. 

Hydrocephalus,  five  cases  ;  one  cured. 

Paralysis  agitans,  six  cases. 

Sequelas  of  concussion  of  the  brain,  three  cases. 

Delirium  tremens,  one  case  ;  cured. 

Chorea,  two  cases  ;  both  cured. 

Epilepsy. —  Grand  mal,  four  cases;  one  cured.  Petit  mal, 
one   case  ;    cured. 

Writer's  cramp,  two  cases  ;  one  cured. 

Hj'steria,  fifteen  cass  ;  five  cured. 


DISEASES  OF   THE  NERVOUS  SYSTEM  397 

Neurasthenia,  mental  overstrain,  S:c.,  thirty-two  cases;  eleven 
cnred. 

Raynaud's  disease,  one  case. 

Syphilitic  dementia,  one  case. 

Mania,  four  cases  ;  two  cured. 

Melancholia,  one  case. 

Insanity  of  menstruation,  one  case  ;  cured. 

The  treatment  was  without  effect  in  the  following  cases  : — 
A  child,  aged  9,  suffering  from  cerebral  hiemorrhage  of  four  years' 
standing.  Previous  treatment  :  drugs  and  electricity.  Duration 
of  the  manual  treatment  :  three  weeks. 

A  man,  aged  42,  suffering  frona  spastic  paraplegia  (spinal) 
which  ran  a  rapid  course  :  The  patient  first  noticed  that  some- 
thing was  wrong  during  June,  1899 ;  he  was  compelled  to  cease 
work  during  July,  1899.  During  August  and  September  of  the 
same  year  he  underwent  five  weeks  of  electrical  treatment. 
Duration  of  the  manual  treatment:  October  1,  1899,  to 
January  10,  1900.     Patient  died  during  October,  1900. 

Embolism  into  the  Internal  Capsule. 

H.  A.,  female,  aged  39,  came  under  the  manual  treatment  on 
August  8,  1900. 

History  of  present  illness. — Patient  had  been  suffermg  since 
187G  from  heart  disease,  which  was  quite  well  compensated. 
During  March,  1899,  she  had  an  attack  of  influenza,  and  got  up 
too  soon  after  it.  A  relapse  took  place,  and  during  the  night  of 
April  1,  1899,  she  suddenly  lost  consciousness  for  an  hour  and 
awoke  with  complete  paralysis  of  the  left  side  of  the  body  (face, 
arm,  and  leg),  with  transient  aphasia  which  lasted  twenty-four 
hours.  After  stopping  at  home  for  two  weeks  she  was  taken,  on 
April  17,  1899,  to  the  hospital  in  Hvetlanda,  where  she  remained 
until  May  19,  1899.  Her  condition  did  not  improve  much  ;  some 
power  of  movement  at  the  elbow  and  slight  power  of  movement 
in  the  lower  extremity  returned  gradually. 

She  then  went  to  a  convalescent  home,  and  took  baths  for  two 
months  from  June  1  to  July  31,  1899.  She  then  left,  and  under- 
went electrical  treatment  for  a  month,  after  which  she  went 
home.  No  further  treatment  was  taken  until  May,  1900,  when 
massage  was  resorted  to  ;  this  was  continued  until  August,  when 
patient  came  to  me. 


398     ELEMENTS  OF  KELLGREN'S   MANUAL   TREATMENT 

She  said  Unit  none  of  the  treatment  undergone  had  ever 
seemed  to  do  her  any  good  worth  mentioning,  and  that  she  only 
improved  at  the  same  rate  (a  very  slow  one)  while  massage  or 
electricity  was  being  administered  as  while  not  under  treatment 
at  all. 

Examination. — Patient  still  had  some  facial  paralysis  on  the 
left  side ;  when  smiling  the  right  side  of  the  mouth  drew 
back,  but  the  left  remained  stationary.  She  walked  very  slowly 
with  the  help  of  a  stick,  and  swung  her  left  leg  round  in  a 
semi-circle.  On  her  journey  to  Sanna  she  had  to  walk  from 
one  station  to  another ;  the  distance  was  only  three-quarters  of  a 
mile,  but  took  her  three  hours  to  accomplish. 

Left  side  of  body  :  Reflexes. — There  was  slight  knee  clonus, 
and  some  ankle  clonus;  the  patellar  reflex  was  exaggerated. 
There  was  a  biceps  jerk,  but  not  an  extensor  one.  Frictions  on 
the  posterior  interosseous  nerve  caused  twitching  of  the  fingers 
(dorsifiexion) .  Frictions  over  the  musculo-spiral  nerve  produced 
this  to  a  less  extent.  Repeated  frictions  on  the  internal  plantar 
nerve  caused  a  little  flexion  of  the  hip-joint  (see  p.  151). 

Most  of  the  muscles  were  stiff  in  the  affected  areas,  excepting 
in  the  thigh,  where  some  of  them  were  flabby ;  there  was,  how- 
ever, no  actual  wasting.  Occasionally  involuntary  spasmodic 
movements  took  place  in  the  fingers,  but  nowhere  else. 

Voluntary  movements : — 

Shoulder-joint. — Flexion,  fair,  through  angle  of  90°  or  so. 
Extension,  hardly  any.  Internal  rotation,  good.  External 
rotation,  very  little.  Abduction,  arm  could  not  be  abducted  to 
right  angle.  Adduction,  good.  Elbow  pressing  backwards,  upper 
arm  could  not  be  pressed  backwards  to  form  less  than  45°  with 
coronal  plane.  Patient  could  not  put  her  arm  in  neck  firm 
position,  or  keep  it  there  when  so  placed  for  her  while  she  was  in 
half  lying  position. 

Elbow-joint. — Flexion,  good,  but  muscles  very  stiff.  Extension, 
weak. 

Radio-ulnar  joints. — Supination,  impossible  to  more  than 
mid-position.     Pronation,  good. 

Wrist  and  finger-joints. — Flexion,  normal,  but  patient  unable 
to  close  her  fist.  Extension,  hardly  any  ;  extension  of  -thuml)  a 
little  better  than  that  of  fingers. 

'     Hip-joint. — Abduction,  weak.     Adduction,  normal.     Flexion, 
very  little.     Extension,  fair.     Rotations,  very  weak. 


DISEASES  OF  THE  NERVOUS  SYSTEM  399 

Knee-joint. — Flexion,  very  weak.  In  forward  13'ing  position 
patient  was  unable  to  lift  her  foot  off  the  couch,  although  she  was 
able  to  contract  the  hamstring  muscles.     Extension,  good. 

Ankle-joint. — Flexion,  none.     Extension,  good. 

Toe-joints. — Slight  movements  possible. 

Face. — See  above. 

Sensation  was  quite  good  in  the  paralysed  area.  The  pupils 
were  normal. 

Heart  symptoms. — Patient  complained  of  a  continued  anxious 
feeling  in  the  cardiac  region.  The  cardiac  impulse  could  be  seen 
in  the  fifth  and  sixth  spaces  in  the  nipple  line.  On  percussion, 
there  was  some  enlargement  to  the  right  of  the  sternum.  On 
auscultation,  great  arhythmia  with  pauses  and  intermissions  ; 
the  sounds  were  verj-  indistinct,  varied  very  much,  and  occasion- 
ally almost  disappeared  for  a  few  beats.  A  diastolic  murmur  could 
be  heard  in  the  mitral  area ;  it  was  slightly  propagated  into  the 
axilla.  Pulse  about  150 ;  there  was,  however,  great  difiiciilty  in 
counting  it,  owing  to  the  great  irregularity.  Sphygmographic 
tracing  taken  before  treatment  see  fig.  136. 


Treatment, 

(1)  Sitting  head  exercise,  PP,  including  frictions  on  the  left 
facial  nerve,  PP. 

(2)  Sitting  left  arm  exercise,  including  arm  abduction,  Alt, 
adduction,  PE  :  supination,  AR,  pronation,  PR  ;  elbow  extension. 
AR,  flexion,  PR  ;  finger  and  wrist  extension,  AR,  flexion,  PR  : 
nerve  frictions,  specially  on  the  posterior  interosseous  nerve,  PP. 

(3)  Half  lying  double  arm  rolling,  PP,  bending,  PR,  stretching, 
AR. 

(4)  Half  lying  double  foot  rolling,  PP,  flexion  and  extension, 
AR. 

(5)  Forwards  lying  Ijack  exercise,  PP,  knee  flexion,  AR. 
extension,  PR. 

(6)  Half  lying  leg  rolling,  PP,  flexion,  AR,  extension,  PR. 

(7)  Half  lying  stomach  exercise,  heart  vibrations,  side  shaking, 
PP. 

Extra  movements  were  often  included,  but  the  above  formed 
the  general  prescription.     ^All  the  movements  had  to  be  adminis- 


400      ELEMENTS  OF  KELLGREN'S  MANUAL  TREATMENT 

iered  carefully,  in  consequence  of  the  cardiac  condition.  In  many 
cases  the  first  part  of  the  duphcate  movements,  as  in  (2),  were 
^dven  PP  at  first,  then  PA,  and  then  AK,  si'fidually  increasing 
I'esistance  being  offered  as  the  patient's  strength  came  back. 


Progress. —  August    8. — -After   the    first    treatment    the    toes 
already  able  to  move  a  little  better. 

August  9. — The  heart  qnietei',  according  to  the  patient.     Less 


DISEASES  OF  THE  NERVOUS  SYSTEM  401 

feeling  of  anxiety  in  the  heart,  which  could  be  felt  to  beat  more 
slowly  but  just  as  irregularly. 

August  10. — Patient  able  to  abduct  her  arm  to  more  than  a 
right  angle.  The  extensors  of  the  forearm  stronger.  Movements 
of  the  toes  a  little  better.  Patient  able  to  walk  better.  The 
anxious  feeling  in  her  heart  quite  gone. 

August  15. — The  facial  paralysis  disappeared.  The  extensors 
of  the  forearm  and  abductors  of  the  shoulders  stronger.  Patient 
able  to  walk  better  and  without  using  a  stick. 

August  21. — -Improvement  continued.  Complete  supination 
possible. 

August  24. — Extensors  of  forearm  and  abductors  of  shoulder 
stronger ;  abduction  now  possible  through  120°. 

September  3. — Abduction  at  the  shoulder  possible  through 
135°.  The  elbow  could  be  drawn  back  to  form  an  angle  of 
about  22°  with  the  coronal  plane. 

September  15.— Further  improvement  in  abduction,  which 
was  now  possible  through  150°.  Patient  could,  in  forwards  lying 
position,  flex  her  knee  a  little  and  resist  during  extension.  The 
stiffness  of  the  muscles  previously  felt  while  administering  leg 
rolling  and  arm  rolling  almost  gone,  but  the  range  of  passive 
flexion  and  extension  at  the  ankle  not  complete  ;  the  toes  able 
to  move  through  an  arc  of  only  about  2  inches.  Patient  able 
to  use  the  fingers  of  the  left  hand  to  button  her  clothes  if  the 
buttons  were  in  a  convenient  position  in  front. 

September  18. — Patient  took  a  walk  of  four  miles,  half  of 
which  was  very  much  uphill. 

October  1. — Treatment  now  as  follows  : — 

(1)  Sitting  head  exercise,  PP,  frictions  on  the  left  facial 
nerve,  PP. 

(2)  Heave  grasp  standing  drawing  forwards,  PP,  heart  vibra- 
tion, PP. 

(3)  Sitting  left  arm  exercise,  as  before. 

(4)  Half  lying  double  foot  rolling,  PP,  flexion,  AR,  extension, 
PR. 

(5)  Half  lying  double  arm  rolling,  PP,  bending,  PR,  stretch- 
ing, AR. 

(6)  Forwards  lying  back  exercise,  PP,  knee  flexion,  AR, 
extension,  PR. 

(7)  Half  lying  leg  rolling,  PP,  flexion,  AR,  extension,  AR. 
26 


402     ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

(8)  Half  lying  stomach  exercise,  heart  vibration,  side  shaking, 
PP. 

October  o. — Abduction  of  arm  possible  nearly  up  to  the 
vertical.     Elbow  could  be  drawn  back  to  coronal  plane. 

October  14. — Left  arm  could  be  placed  m  neck  firm  position 
(when  patient  in  half  lying  position),  and  kept  there  with  difficulty. 

October  23. — Patient  able  to  extend  fingers  and  wrist  to  lie  in 
straight  line  with  forearm. 

November  1. — Patient  able  to  extend  fingers  and  wrist  to  more 
than  a  straight  line  with  the  forearm  ;  able  to  walk  quicker. 
Flexion  of  knee  better. 

November  5. — Extension  of  thumb,  PA,  normal. 

November  28. — Sphygmographic  tracing  taken  to-day  half 
an  hour  after  treatment,  see  fig.  137, 


Examination. — December  20,  1900.  Patient  able  to  walk 
much  better  than  when  she  first  came  to  me.  The  reflexes  about 
the  same  as  on  August  8. 

Voluntary  movements  : — 

Shoulder-joint. — Flexion,  good.  Extension,  weak.  Internal 
rotation,  normal.  External  rotation,  good,  possible  with  a  good 
deal  .of  AR.  Abduction  good,  possible  to  nearly  the  vertical. 
Adduction,  good.     Elbow  pressing  backwards,  very  good. 

Elbow-joint. — Flexion,  normal.  Extension,  possible  to  a 
straight  line. 

liadio-ulnar  joints. — Supination,  possible  to  full  extent  with 
AR.     Pronation,  good. 

Wrist  and  finger-joints. — Flexion,  patient  able  to  close  her  fist. 
Extension,  fingers  and  wrist  capable  of  extension  to  a  straight 
line,  or  even  a  little  more  sometimes.  Complete  extension  of 
thumb  possible  with  All. 


DISEASES  OF   THE  NERVOUS    SYSTEM  403 

Hip-joint. — Abduction,  normal.  Adduction,  normal.  Flexion, 
good.     Extension,  very  good.    Rotations,  very  little  improvement. 

Knee-joint. — Flexion,  in  forwards  lying  position  patient  able 
to  flex  the  knee  to  a  right  angle  and  resist  in  extension,  PE. 
Extension,  good. 

Ankle-joint. — Flexion,  good.     Extension,  normal. 

Toe-joints. — Flexion,  fair.     Extension,  good. 

Face. — Normal. 

Heart  symptoms. — The  apex  beat  nearer  the  sternum  than 
before.  The  area  of  cardiac  dulness  less  than  when  she  first 
came  under  the  manual  treatment.  On  auscultation  the  diastolic 
murmur  not  so  distinct  as  it  was  ;  the  heart  sounds  less  faint  and 
the  irregularity  less.     Sphygmographic  tracing  (see  fig.  138). 


Infantile  Spastic  Diplegia. 

A.  J.,  male,  aged  H,  came  under  the  manual  treatment  on 
August  8,  1901. 

History  of  present  illness. — Patient  was  a  first  child  ;  the 
labour  was  not  abnormal,  no  forceps  being  used,  and  from  first  to 
last  occupied  about  twenty  hours.  The  condition  of  spastic 
diplegia  was,  however,  noticed  soon  after  birth,  and  had  persisted 
ever  since  with  hardly  perceptible  change.  Several  medical  men 
who  were  from  time  to  time  consulted  pronounced  the  condition 
to  be  incurable. 

Examination. — I  am  indebted  to  Dr.  Harry  Kellgren  for  the 
following  description  of  the  patient's  condition  on  August  8. 
Face  expressionless,  very  pale.  Head  large,  hydrocephalic  look- 
ing, circumference  55  cm.  Intelligence  weak,  patient  could  hardly 
talk  at  all ;  his  vocabulary  was  hmited  to  five  or  six  words.  No 
nystagmus.  Patient  continually  in  the  attitude  characteristic  of 
iiis  disease — upper  arms  add  acted  and  rotated  internally  ;    elbows 


404   ELEMENTS   OF   KELLGREX'S    MANUAL    TREATMENT 

semi-flexed,  forearms  pronated,  hands  semi-flexed  and  meeting 
anteriorly  across  the  chest.  Thighs  markedly  adducted,  semi- 
flexed, rotated  inwards ;  knees  semi-flexed,  feet  extended  and 
inverted.     Spine  somewhat  kyphosed. 

General  weakness  of  all  muscles.  Cervical  extensors  very 
weak  ;  patient  unable  to  hold  his  head  up  ;  it  always  fell  to  one 
or  other  side  unless  supported.  The  arm  muscles  flabby,  those 
of  the  legs  somewhat  spastic.  The  contraction  in  the  adductor 
muscles  so  strong  that  the  knees  could  passively  be  only  very 
slightly  separated.  Patient  unable  to  sit  up  unless  with  a  great 
deal  of  support ;  and  unable  to  stand  up  against  a  wall  unless 
with  very  complete  fixation,  the  least  relaxation  of  the  support 
causing  him  to  fall  down  in  a  heap.  Arms  very  rarely  moved  ; 
attempts  to  get  patient  to  move  them  voluntarily  quite  unsuccess- 
ful. Legs  often  moved  ;  and  patient  would  move  them  when 
ordered  to  do  so,  although  he  was  apparently  unable  to  perform 
half  lying  leg  extension,  PA,  after  the  thigh  and  knee  had  first 
been  passively  flexed.  Patient  unable  to  straighten  his  spine 
voluntarily. 

Eeflexes.  Eyes  reacted  sluggishly  to  light.  Babinsky's  sign 
and  Kellgren's  plantar  sign  present.  Tendo  Achillis  jer-k,  ankle 
clonus,  and  adductor  jerk  present  on  both  sides ;  no  knee 
clonus  or  crossed  adductor  jerk.  Patellar  reflexes  very  exag- 
gerated. The  reflexes  of  both  legs  about  equal.  No  reflexes 
in  the  upper  arms.  Defaecation :  for  the  first  six  months 
of  his  life  patient  was  constipated,  and  an  enema  was  admin- 
istered daily.  After  that  time  the  reverse  condition  set  in, 
and  patient  had  since  had  seven  or  eight  motions  per  day. 
Micturition :  this  was  frequent,  often  every  hour  during  the 
daytime  and  severaltimes  during  the  night.  No  incontinence 
either  of  faeces  or  urine  ;  patient  had  learnt  to  give  the  sign 
to  his  nurse  when  he  wished   to  empty  rectum  or  bladder. 

Treatment. 

(1)  Sitting  head  exercise,  PP. 

(•2)  Half  lying  double  arm  rolling,  PP,  bending  and  stretch- 
ing, AB,  arm  nerve  frictions,  suprascapular  nerve  frictions,  PP. 

(3)  Stretch  grasp  standing  drawing  forwards,  side  shaking,  PP. 

(4)  Half  lying  double  foot  rolling,  PP,  flexion  and  extension. 


DISEASES   OF   THE  NERVOUS  SYSTEM         '       405 

AE  ;  double  leg  rolling,  PP,  flexion  and  extension,  AR,  leg  nerve 
frictions,  PP. 

(5)  Crook  half  lying  double  knee  abduction,  AR,  adduction, 
PR. 

(6)  Forwards  lying  back  exercise,  PP. 

(7)  Sitting  trunk  extension  and  flexion,  PA ;  sit  lying  knee 
extension  and  flexion,  PP,  extension,  AR,  flexion,  PR. 

(8)  Stretcli  half  lying  running  nerve  frictions,  PP,  shaking 
over  the  bladder,  PP. 

(9)  Half  lying  stomach  exercise,  PP. 

(10)  Patient  was  made  to  try  and  walk,  and  to  stand  with  as 
little  support  as  possible. 

The  above  exercises  could  not,  of  course,  be  executed  at  once 
with  the  proper  resistance  ;  several  weeks  of  careful  training  were 
necessary  before  the  patient  could  learn  what  to  do. 

Progress. — I  first  saw  patient  on  October  1.  He  was  already 
better.  The  face  had  more  expression,  was  more  lively  and  had 
more  colour.  Patient  was  able  to  hold  up  his  head  by  himself, 
and  if  properly  balanced  could  sit  up  by  himself  without  support 
for  ten  or  fifteen  seconds.     He  could  also  flex  and  extend  arms. 

October  11.  —  While  receiving  forwards  lying  back  exercise, 
PP,  patient  held  up  his  head  quite  well. 

October  1.5. — When  held  up  under  both  arms,  patient  was  able 
to  put  one  foot  in  front  of  the  other  so  as  to  walk  along,  though 
this  was  accomplished  with  a  good  deal  of  difficulty  ;  the  right  leg 
moved  more  easily  than  the  left. 

October  17. — While  in  forwards  lying  position,  patient  was 
able  to  resist  while  his  head  was  pressed  down  on  to  the  couch, 
and  also  to  raise  it  again  with  AR.  He  had  to  a  great  extent  lost 
the  characteristic  attitude  of  his  disease. 

November  9. — Cervical  extensors  still  stronger.  Walking 
(with  support)  better.  Patient  able  for  the  first  time  to  stand 
upright  with  his  back  against  a  wall  with  hardly  any  support.  He 
could  now  perform  half  lying  leg  extension,  AR. 

November  18. — Patient  able,  when  holding  on  to  a  sofa  for 
assistance,  to  walk  a  few  steps. 

November  23. — Intelligence  improved  ;  face  more  expressive 
and  of  quite  a  good  colour.  Head  smaller,  and  usually  held  up. 
Patient  able  to  sit  up  by  himself  with  only  his  back  supported 
sometimes   for  fifteen  or  twenty   minutes  without  falling ;    and 


4o6  ELEMENTS  OF   KELLGREN'S   MANUAL    TREATMENT 

able,  when  holding;  on  to  a  sofa,  to  walk  fairly  well.  He  went 
home  for  two  days,  but  in  consequence  of  his  nurse  leaving 
suddenly  while  at  home,  and  his  mother  being  unable  to  get 
another,  he  did  not  return  to  treatment.  Winter  set  in,  and 
his  mother  thought  it  better  to  keep  him  at  home  until  the 
spring. 

During  the  winter  patient  had  whooping  cough,  and  a  very 
bad  attack  of  acute  tonsillitis.  He  returned  to  treatment  on 
May  5,  1902. 

The  characteristic  attitude  of  the  disease  had  partly  returned  ; 
the  forearms  were  constantly  pronated,  and  there  was  more 
adductor  contraction  than  during  November.  He  was  still  able 
to  hold  his  head  up  quite  well.  His  intelligence  was  much 
improved,  and  he  talked  a  good  deal.  He  was  unable  to  walk  as 
well  as  when  he  left ;  this  was  owing  to  the  fact  that  his  parents 
had  not  encouraged  him  to  try  and  do  so.  Reflexes  about  the 
same,  with  the  exception  that  there  was  no  ankle  clonus  on  the 
left  side. 

Gymnastic  prescription  same  as  before. 

The  treatment  was  continued  until  July  1,  1902. 

Examination. — July  1. — Patient  had  a  lively  expression,  and 
talked  and  laughed  like  other  children ;  his  speech  was  that  of  a 
child  about  3  years  of  age.  Head  smaller,  circumference  SSi  cm. 
His  intelligence  was  much  improved ;  he  understood  everything 
that  his  nurse  told  him.  The  characteristic  attitude  of  his 
disease  was  gone  ;  very  little  adductor  contraction  was  left.  He 
was  much  stronger,  and  able  to  use  his  arms  and  hands  quite 
well  ;  he  could,  for  example,  take  up  a  cup  with  both  hands, 
drink  out  of  it  and  set  it  down  again  without  upsetting  it. 

He  was  able  to  sit  in  a  chair  without  support  for  periods 
sometimes  as  long  as  ten  minutes.  If  he  held  on  to  the  back  of 
a  sofa,  he  was  able  to  walk  along  it,  though  this  was  done 
clumsily.  He  could  stand  quite  easily  if  allowed  to  hold  on  to  a 
chair.  He  had  learnt  to  do  all  the  duplicated  gymnastic  exercises 
quite  well,  and  could  offer  a  good  deal  of  resistance  during  crook 
half  lying  double  knee  adduction,  PR. 

Reflexes.  The  eyes  reacted  normally  to  light.  The  reflexes 
of  the  left  leg  were  not  so  marked  as  those  of  the  right. 
Babinsky's  sign  manifested  itself  in  the  right  foot  only  after 
repeated    efforts ;     no    tendo    Achillis     jerk ;    no    ankle    clonus 


DISEASES  OF   THE    NERVOUS   SYSTEM  407 

in  the  left  foot,  one  or  two  jerks  in  the  right  toot.  The  patellar 
reflex  was  more  exaggerated  on  the  right  side  than  on  the  left. 
Deffecation  and  micturition  were  practically  normal. 

I  again  saw  patient  on  September  1(5,  1902.  His  general 
condition  was  improved.  He  was  as  intelligent  as  any  ordinary 
child  of  the  same  age.  His  memory  seemed  quite  up  to  the 
standard.  He  used  his  arms  quite  easily.  There  was  hardly  any 
adductor  contraction,  and  he  was  able  to  walk  for  an  hour  if  he 
held  on  to  something.  Patient  had,  however,  lately  been  having 
cramp  in  the  muscles  of  his  feet.  The  reflexes  were  more  marked 
than  on  July  1 ;  Babinsky's  sign  was  easily  obtainable  in  both 
legs ;  ankle  clonus  was  easily  obtainable  in  right  foot,  and  one  to 
two  jerks  in  left  foot.     Defsecation  and  micturition  normal. 

Diplegia  from  Cerebral  Haemorrhage. 

G.  C,  female,  aged  U,  came  under  the  manual  treatment  on 
January  7,  1902. 

History  of  present  illness. — Patient  had  always  been  well 
until  December  27,  1899,  when  she  was  the  subject  of  an 
apoplectic  seizure.  She  was  heard  during  the  night  to  scream 
suddenly ;  for  several  hours  after  that  she  suffered  from  violent 
convulsions,  retraction  of  the  head,  rolling  up  the  eyes  so  that 
only  the  whites  were  visible,  and  screaming  at  intervals.  The 
parents  did  not  notice  that  the  head  was  turned  to  any  particular 
side.  During  all  this  patient  was  profoundly  unconscious.  After 
a  few  hours  she  quieted  down  somewhat  and  finally  went  to  sleep. 
On  waking  up  the  following  morning  she  seemed  in  a  stupor,  and 
was  entirely  unable  to  move  any  part  except  her  head ;  and  her 
mother  on  trying  to  move  her  found  that  she  was  very  stiff. 
Motor  aphasia  was  present,  and  incontinence  of  fteces  and  urine. 
After  a  week  or  so  partial  power  of  movement  was  restored,  com- 
mencing in  the  legs,  and  patient  was  able  to  say  one  word — 
"  Mamma."  Speech  improved  slowly,  and  was  restored  at  the  end 
of  a  month ;  but  patient  was  unable  to  move  much,  and  remained 
in  bed  during  eight  months.  The  stiffness  of  the  body  and 
extremities  improved  slowly,  and  during  May,  1900,  she  could 
sit  up,  but  not  stand.  During  August,  1900,  she  could  stand  and 
walk  a  few  steps  when  her  mother  supported  her  on  one  side, 
using   a   stick   on   the   other.      During    the    following   summer 


408      ELEMENTS  OF  KELLGREN'S  MANUAL    TREATMENT 

she  was  able  to  waddle  along  very  slowly  and  clumsily  without 
help.     Since  then  her  condition  had  remained  about  the  same. 

Several  medical  men  were  consulted,  who  at  different  times 
prescribed  various  medicines,  but  none  seemed  to  do  her  any 
good.  Since  the  summer  of  1901,  five  medical  men,  consulted 
separately,  declared  that  no  improvement  was  possible  by  any 
method  whatsoever. 

Examination. — January  7,  1902. — Patient  walked  extremely 
clumsily ;  she  was  unable  to  progress  in  a  straight  line,  and 
moved  sideways,  taking  very  small  steps  in  a  more  or  less  circular 
path  ;  her  body  swayed  about  very  much  in  so  doing.  She  was 
unable  to  lift  either  foot  more  than  one  inch  off  the  ground. 
There  was  internal  rotation  and  adduction  of  both  thighs,  and 
inversion  of  both  feet,  so  that  while  walking  patient  kept  her  toes 
almost  touching  and  her  heels  at  least  6  inches  apart,  being 
supported  on  the  outer  side  of  both  feet.  The  right  arm  was  kept 
constantly  with  the  upper  arm  somewhat  abducted,  the  elbow 
semiflexed,  the  forearm  pronated,  and  the  wrist  and  fingers 
flexed  ;  the  arm  could  be  passively  straightened  so  as  to  hang 
vertically,  but  the  least  disturbing  sound  or  putting  a  question 
caused  it  at  once  to  resume  its  former  position. 

Sensory  phenoviena. — Patient  was  perpetually  scratching  her- 
self on  the  right  arm  and  leg  in  consequence  of  itching  feelings 
in  the  skin  ;  these  were  present  to  a  less  extent  in  the  left  hand 
and  foot.  She  also  complained  of  constant  pins  and  needles 
sensations  in  the  right  hand  and  both  feet.  She  generally 
referred  a  touch  on  the  right  leg  to  the  left  one,  and  could  not 
well  locate  points  touched  on  the  right  leg.  A  touch  on  the  right 
arm  was  sometimes  referred  to  the  left  arm.  There  was  dimin- 
ished sensation  in  the  right  hand  and  both  feet.  Sensation  in 
the  left  arm  and  leg  was  referred  correctly.  There  was  no  cold 
shivers  sensation  on  receiving  cervical  nerve  frictions,  nor  any 
sensation  in  the  hand  or  any  part  of  the  arm  except  at  the  point 
of  application  when  receiving  frictions  on  the  brachial  plexus 
in  the  axilla,  nor  in  the  lower  leg  or  foot  when  receiving  internal 
popliteal  nerve  frictions. 

The  sight  appeared  to  be  normal ;  I  could  not  test  patient 
with  the  test  types,  as  she  had  never  learnt  to  read.  No  reaction 
to  accommodation  was  present,  although  that  to  light  was  par- 
tially present.     Ophthalmoscopic   examination  revealed  nothing 


DISEASES  OF   THE   NERVOUS   SYSTEM  409 

abnormal.  Hearing  :  Right  ear  J^,  left  ear  j'^.  Taste  and  smell 
were  normal. 

Reflexes. — Swallowing  normal.  Micturition:  there  was  per- 
petual incontinence  of  urine,  which  patient  did  not  notice  more 
than  about  once  an  hour  or  so,  when  apparently  a  larger  quantity 
than  usual  was  discharged.  Deftecation  :  patient  had  at  least 
three  loose  motions  during  the  day,  and  the  same  number  during 
the  night ;  she  felt  them  coming,  but  could  not  keep  them  in 
more  than  half  a  minute  or  so. 

The  skin  reflexes,  including  Babinsky's  sign,  were  absent. 
Other  reflexes  were  as  follows  :  — 


Kellgren's  plantar  sign 

Kellgren's  crossed  plantar  sign  (see  p.  151 

Tendo  Achillis  jerk 

Ankle  clonus 

Patellar  jerk 

Knee  clonus 

Adductor  magnus  jerk 

Crossed  adductor  jerk 

Extensors  of  forearm  jerk 

Supinator  longus  jerk        

Biceps  jerk    ... 
Triceps  jerk  ... 


Lett  side. 

R 

-ht  side. 

yes 

yes 

no 

yes 

.Ves 

yes 

no 

no 

exaggerated 

much 

exaggerated 

slight 

one 

kick  back 

yes 

no 

Motor  functions. — The  walk  has  been  described.  Patient 
was  very  restless,  perpetually  on  the  move  ;  there  were  continual 
involuntary  movements  of  the  arms,  especially  of  the  right  one. 
There  was  great  weakness  of  many  groups  of  muscles,  and  partial 
weakness  of  almost  all  others.  When  placed  in  a  lying  position 
on  the  floor  patient  was  unable  to  get  up  by  herself  unless  she 
had  a  chair  or  low  stool  to  catch  hold  of ;  even  then  she  had 
great  difficulty,  taking  from  half  a  minute  to  a  minute  to  complete 
the  operation. 

The  tongue  was  protruded  easily,  and  in  the  middle  line. 
The  cervical  extensors  and  spinal  extensors  were  fairly  strong. 
There  was  great  weakness  in  all  the  muscles  of  the  arms,  and 
almost  complete  paralysis  of  both  triceps  muscles  and  the 
extensors  on  the  back  of  the  right  forearm,  those  of  the  forefinger 
being  better  than  those  of  the  little  finger.  Patient  was  unable 
to  abduct  either  arm  to  a  right  angle  ;  there  was  limited  supina- 
tion of  the  right  forearm.  She  never  used  her  right  arm  for  any- 
thing ;  on  being  asked  to  use  it  to  pick  up  a  light  article,  such  as  a 


4IO     ELEMENTS  OF   KELLGHEN'S   MANUAL    TREATMENT 


match-box,  from  a  table,  she  proceeded  just  as  it'  afflicted  with 
chorea  and  generally  failed  to  pick  it  up ;  if  she  succeeded  she 
generally  dropped  it  a  second  or  two  later.  When  put  on  a  chair 
she  could  touch  her  feet  with  her  right  hand,  but  not  without 
lifting  her  foot  off  the  ground  at  the  same  time.  The  left  arm 
was  also  very  weak,  but  she  could  use  her  left  hand  quite  well, 
though  choreic-like  movements  were  often  seen  in  it.  At  meals 
she  used  only  her  left  hand.  She  was  quite  unable  to  dress 
herself,  but  could  fasten  a  button  in  front  of  her  dress  with  both 
hands,  proceeding  just  as  in  a  case  of  ordinary  chorea,  and  taking 
from  one  to  two  minutes.  She  could  not  put  her  right  arm  into 
hip  firm  position,  and  could  not  keep  her  arms  in  neck  firm 
position  when  they  were  passively  placed  so  while  she  was  lying 
down. 

There  was  complete  paralysis  of  the  external  rotators  of  both 
thighs  and  eversors  of  both  feet  ;  patient  could  not  lie  wdth  her 
heels  nearer  than  6  inches  apart.  The  glutei  maximi  were  fairly 
strong.  There  was  considerable  weakness  of  the  abductors  of  the 
thighs  and  partial  contracture  in  the  adductors  of  the  left  side. 
The  extensors  of  the  knees  were  in  good  condition, -and  had  suffered 
least  in  the  general  atrophy.  There  was  almost  complete  paralysis 
of  the  flexors  of  the  left  foot.  The  anterior  abdominal  muscles 
were  weak. 

When  administering  leg  rolling,  spasticity  of  the  muscles 
could  to  some  degree  be  felt.  Such  spasticity  could  not  be 
detected  in  the  arms  or  trunk. 

Measurements  as  follows  : — 


Ankle,  minimum  just  above 

Calf,  maximum 

Thigh,  minimum    ... 

Wrist,  minimum  just  above 

Forearm,  maximum 

Upper  arm,  minimum  just  above  elbow-joint 

Middle  of  upper  arm  


Left  side. 

Right  side 

15    cm. 

15   cm. 

22     „ 

23      „ 

25     „ 

24i  „ 

11      „ 

11     .. 

15*  „ 

"i  „ 

14      ,, 

14     „ 

13     ,, 

13     „ 

Patient's  intelligence  was  good,  and  her  speech  normal.  She 
slept  fairly  well,  but  talked  at  intervals  of  a  few  minutes  during 
most  of  the  night ;  sometimes  she  shouted  and  made  violent 
movements,  which  occasionally  woke  her  np.  She  also  woke 
every  time  she  was  going  to  have  a  motion.  The  heart  and 
lungs  were  normal. 


DISEASES   OF   THE   NERVOUS  SYSTEM  411 

Treatment. 

(1)  Sitting  head  exercise,  PP. 

(2)  Forwards  lying  back  exercise,  PP. 

(3)  Half  lying  foot  rolling,  PP  ;  peroneal  muscle  kneading, 
PP  ;  eversion,  PA,  inversion,  PR  ;  external  popliteal  and 
musculo-cutaneous  nerve  frictions,  PP  ;  left  foot  flexion,  PA, 
extension,  PR. 

(4)  Half  lying  leg  rolling,  PP,  flexion,  PA,  extension,  AR  ; 
leg  nerve  frictions,  PP. 

(5)  Half  lying  double  leg  rotation  externally,  PA,  internally, 
PR  ;  double  leg  abduction,  PA,  adduction,  PR. 

(6)  Half  lying  double  arm  rolling,  PP,  bending  and  stretch- 
ing, AR. 

(7)  Half  lying  stomach  exercise,  PP ;  shaking  over  the 
bladder,  and  sacral  nerve  frictions,  PP. 

(8)  Sitting  left  arm  exercise,  including  supination,  AR, 
pronation,  PR;  hand  and  finger  extension,  PA,  flexion,  PR; 
elbow  extension,  PA,  flexion,  PR,  &c. 

(9)  Sitting  right  arm  muscle  kneading,  running  nerve  frictions, 
&c.,  PP. 

(10)  Swim  sitting  double  elbow  pressing  downwards,  PR, 
upwards,  AR. 

(11)  Heave  sitting  double  forearm  extension,  AR,  flexion, 
AR. 

(12)  Patient  was  made  to  practise  walking  round  the  room 
for  a  few  minutes. 

Progress. — January  15. — Patient  already  able  to  walk  better. 

February  4. — Patient  able  to  walk  better,  and  with  feet 
straight  {i.e.,  parallel  to  one  another),  in  a  room  where  there  was 
a  carpet,  although  she  was  unable  to  do  so  on  bare  boards  ;  she 
did  not  move  her  body  so  much  while  walking.  Extensors  of 
fingers  and  wrist  of  right  hand  better.  Sensation  in  fingers 
during  brachial  plexus  frictions  in  the  left  arm. 

February  6. — Sensation  in  fingers  during  brachial  plexus 
frictions  in  the  right  arm.  Abduction  of  shoulder-joint  better ; 
patient  able  to  hold  out  1  kilo,  at  right  angles  with  right  arm, 
but  not  with  the  left. 

February  10. — Patient  able  to  run  a  few  steps  very  awk- 
wardly, but  then  obliged  to  stop  or  she  would  fall. 


412    ELEMENTS    OF   KELLGREN'S   MANUAL   TREATMENT 

February  19. — Patient  ran  round  the  room  four  times  (about 
twelve  yards  each  time)  in  succession. 

February  28. — Patient  able  to  pick  up  a  pin  off  the  table  with 
right  hand,  although  still  with  choreic-like  movements.  Involun- 
tary movements  of  arms  much  less. 

March  1  to  7.— Mild  attack  of  scarlet  fever  (see  p.  273), 
which  seemed  to  have  some  beneficial  effects.  After  it  the 
incontinence  of  urine  entirely  ceased ;  the  eversors  of  the  right 
foot  and  extensors  of  the  right  hand  were  stronger,  and  patient 
began  to  use  the  latter  when  eating. 

March  10. — Patient,  when  placed  on  the  ground,  able  to  get 
up  without  help  and  able,  when  standing,  to  lift  things  off  the 
ground,  although  she  did  both  awkwardly. 

March  24. — Walk  still  improving  ;  patient  able  to  turn  her 
feet  out  a  little  while  walking.  She  lifted  a  cane  chair  off  the 
ground,  using  both  hands.  Arms  stronger.  Concentric  con- 
traction in  the  eversors  of  both  feet. 

March  28. — Patient  walked  thirty  times  round  the  room 
(twelve  yards  each  time)  without  stopping.  Up  to  the  present 
she  had  been  wheeled  in  a  mail-cart  from  where  she  lived  to  my 
villa  (distance  about  200  yards),  but  on  this  day  she  walked  home 
with  help. 

April  12. — Patient  walked  to  and  from  her  place  of  treatment 
without  any  help  for  the  first  time. 

April  24. — Patient  walked  with  her  feet  turned  outwards. 
Was  able  to  lift  a  piece  of  fine  wire  off  a  table  with  her  left 
hand.  Involuntary  movements  of  arms  almost  gone.  Right 
patellar  reflex  normal,  other  reflexes  about  the  same.  Bladder 
quite  well  since  March  8  ;  still  about  6  motions  every  twenty- 
four  hours. 

Treatment  changed  on  April  27,  1902,  as  follows  : — 

(i)  Sitting  head  exercise,  PP. 

(2)  Forward  lying  back  exercise,  PP;  leg  flexion,  PP,  raising, 
AE. 

(3)  Half  lying  foot  rolling,  &c.,  as  before. 

(4)  Crook  half  lying  double  knee  abduction,  AR,  adduction, 
PR,  leg  nerve  frictions,  PP. 

(5)  Sitting  arm  exercise,  as  before. 

(6)  Half  lying  stomach  exercise,  PP,  shaking  over  the  bladder, 
sacral  nerve  frictions,  PP. 


DISEASES  OF   THE   NERVOUS   SYSTEM  413 

(7)  Reach  grasp  step  standing  knee  flexion  and  extension,  PA. 

(8)  Stretch  grasp  standing  drawing  forwards,  PP,  spinal  nerve 
frictions  PP. 

(9)  Ride  sitting  alternate  rotation,  AR,  ringing,  PP. 
(10)  Practising  to  walk. 

The  treatment  had  to  be  stopped  on  May  7,  1902. 

Examination. — May  7,  1902. — Patient  was  able  to  walk  much 
better,  and  without  assistance,  at  about  the  rate  of  an  ordinary 
person  {i.e.,  about  three  miles  an  hour).  She  turned  out  her 
feet  while  doing  so,  and  was  able  to  keep  her  arms  hanging 
downwards  against  her  sides.  She  could  run  about  seventy- 
five  yards  without  stopping,  although  this  was  done  awkwardly. 
There  was  less  inversion  of  the  feet,  and  less  internal  rotation  of 
the  thighs.  While  sitting  at  ease  the  toes  were  kept  together  and 
the  heels  two  inches  apart.  When  her  feet  were  placed  as  in  the 
standing  position  patient  could  balance  herself  quite  well. 

Sensory  phenomena. — Less  itching,  no  pins  and  needles  sensa- 
tion. No  diminution  of  sensation  or  wrong  reference  of  touch. 
Sensation  felt  down  the  spine  during  cervical  nerve  frictions ; 
sometimes  in  the  hand,  and  always  in  the  upper  arm  during 
brachial  plexus  frictions ;  and  in  the  lower  leg,  although  never  in 
the  foot,  during  internal  popliteal  nerve  frictions.  The  pupils 
reacted  very  slightly  to  accommodation,  and  normally  to  light. 
Hearing  :  Right  ear,  |J,  left  ear,  fg. 

Reflexes. — Micturition  :  normal,  no  more  incontinence.  De- 
falcation :  three  motions  a  day,  but  none  during  the  night. 
When  patient  felt  like  having  a  motion  she  was  able  to  restrain 
it  for  as  much  as  half  an  hour. 

Skin  reflexes  absent.     Other  reflexes  as  follows  : — 


Left  .Side. 

RiKlit  Side. 

Kellgreu's  plantar  sign 

slight 

slight 

Kellgren's  crossed  plantar  sign     . 

no 

no 

Tendo  Achillis  jerk 

no 

no 

Ankle  clonus 

no 

no 

Patellar  jerk 

less  exaggerated     . 

.     less  exaggerated 

than   before 

than  before 

Knee  clonus 

Adductor  magnus  jerk 
Tendon  reflexes  in  arms 


Motor  functions.  —  Patient  much  less  restless  ;  very  few 
involuntary  movements  of  the  right  arm  ;  hardly  any  of  the  left. 
Patient  able  to  get  up  by  herself  without  the  aid  of  a  chair,  &c., 


Left  Side. 

Right  Sidi 

16J  cm.      . 

16  cm. 

m  „       . 

..       251  „ 

27      „ 

..      26    „ 

Hi  „       . 

..       lli„ 

17     „ 

..       17i„ 

14S   ,, 

..       15    „ 

Ui   „ 

15    „ 

414   ELEMENTS   OF   KELLGREN'S    MANUAL    TREATMENT 

when  placed  in  a  lyinr;  position  on  the  floor.  Muscles  as  a  whole 
stronger.  Patient  able  to  perforin  right  forearm  supination,  AR ; 
able  to  pick  up  a  needle  at  once  with  her  right  hand.  When 
standing,  able  to  bend  forwards  and  touch  her  foot  with  her 
hand.  Both  hands  used  when  eating.  Patient  able  to  partially 
dress  herself,  and  when  asked  to  fasten  a  button  in  front  able  to 
do  so,  exhibiting  very  few  choreic  movements,  and  taking 
five  to  ten  seconds  to  accomplish  the  process.  Patient  able  to 
keep  her  arms  in  hips  firm  and  neck  firm  positions  when  stand- 
ing up.  Eversors  of  both  feet,  flexors  of  left  foot,  external 
rotators  and  abductors  of  both  thighs  stronger. 

No  spasticity  of  the  leg  muscles.     Measurements  as  follows: — 

Aukle,  minimum  just  above... 

Calf,  maximum  

Thigh,  minimum        

Wrist,  minimum  just  above  .. 

Forearm,  maximum  ... 

Upper  arm,  minimum  just  above  elbovp-joint 

Middle  of  upper  arm 

Intelligence  better,  general  aspect  of  face  more  lively.     Sleep 
unchanged. 


Sequelae  of  Meningitis  (Syphilitic). 

0.  S.,  male,  aged  32,  came  under  the  manual  treatment  on 
July  8,  1902. 

History  of  present  illness. — ^Patient's  occupation  was  that  of 
worker  in  a  brass  foundry.  Patient's  father  was  ignorant  of  the 
nature  of  syphilis,  but  stated  that  from  December,  1899, 
until  February,  1900,  his  son  seemed  ill  and  weak,  and  had 
a  number  of  large  ulcers  over  his  scalp  and  face,  some  of 
which  were  arranged  in  a  kind  of  ring  round  the  head ;  they 
emitted  a  foul-smelling  discharge.  During  the  same  period 
there  were  likewise  ulcers  on  the  mouth  and  tongue,  and 
the  patient  was  hoarse  ;  his  breath  smelt  very  foul.  Patient's 
father  had  never  noticed  any  sore  on  the  penis  or  any  rash. 
About  February,  1900,  patient  began  to  complain  of  severe 
.  headache,  which  was  worse  during  the  evening.  On  February  13, 
the  headache  was  very  bad  and  accompanied  by  throbbing  feelings 


DISEASES  OF   THE  NERVOUS  SYSTEM  415 

in  the  head,  the  pain  causing  patient  to  walk  about  holding  his 
head  between  his  hands.  During  the  following  day  he  was 
worse,  but  tried  to  work  ;  he  was,  however,  compelled  to  go 
home.  During  February  16  he  was  so  bad  that  he  consulted  a 
medical  man,  who  gave  him  a  prescription.  While  waiting  at 
the  chemist's  to  have  it  made  up,  patient  suddenly  felt  very  ill  and 
lost  consciousness.  After  a  few  seconds  he  came  to  and  went 
through  what  looked  very  like  an  epileptic  fit,  although  he  was 
conscious  meanwhile  and  did  not  fall  into  a  stupor  at  its  close. 
After  it  was  over  he  was  taken  to  a  friend's  house  and  soon 
became  semi-unconscious  and  feverish,  and  had  retraction  of  the 
head.  During  the  same  evening  violent  convulsions  came  on, 
lasting  one  and  a  half  hours.  A  medical  man  was  called  in  and 
diagnosed  meningitis,  stating  that  the  temperature  was  40°  C. 
(104°  F.)  ;  pot.  iod.  was  prescribed.  During  the  night  a  second 
attack  of  convulsions  came  on,  lasting  two  and  a  half  hours. 
After  this  patient  was  almost  completely  unconscious  for  a  week ; 
l)ut  subsequently  he  recovered  slowly,  and  by  about  March  24 
was  so  much  better  that  he  was  allowed  to  return  home.  He 
was,  however,  by  no  means  well  at  this  date  ;  he  seemed  weak, 
apathetic,  dull  of  understanding  and  slow  in  his  movements. 

Since  that  time  (March,  1900)  he  had  slowl}^  become  worse. 
Soon  he  only  spoke  when  addressed,  his  reply  being  in  a  slow 
monotonous  thick  voice ;  as  time  went  on  he  could  only  be 
persuaded  to  speak  with  great  difficulty,  answering  in  whispers. 
After  July,  1900,  he  ceased  to  speak,  but  still  used  to  write  m 
order  to  express  any  wish  ;  after  a  year  he  never  wrote  unless 
asked  to  do  so,  and  at  last,  after  November,  1901,  he  could  not 
even  be  induced  to  write.  During  this  time  he  gradually  became 
slower  in  his  movements,  and  his  face  assumed  a  look  of  deep 
depression.  Treatment  by  medicine  and  baths  did  not  have  the 
least   effect. 

Examination .  —  Ju\y  8,  1902. — Patient  walked  slowly  with  his 
head  bent  forwards  and  his  eyes  looking  downwards,  with  an 
expression  of  intense  melancholia.  His  face  was  flushed  and  the 
sterno-mastoids  could  be  seen  to  stand  out  prominently.  He  was 
round  shouldered  and  his  chest  was  sunk  in.  He  never  spoke, 
smiled,  or  uttered  any  sound  whatever.  He  was  subject  to 
continual  twitching  movements  of  the  nose  and  mouth  ;  and  the 
mouth  was  generally  shaped  as  if  pouting.     He  understood  when 


4i6      ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

spoken  to  in  a  low  voice,  but  executed  orders  to  move,  &c.,  very 
slowly.  When  told  to  sit  down  he  would  do  so,  and  remain 
immovable  for  hours  until  told  to  get  up  and  walk,  whereupon 
he  would  again  comply  and  slowly  walk  up  and  down  until  told 
to  stop.  There  was  a  partially  cataleptic  state  ;  patient  would 
keep  his  arms  or  legs  in  any  position  in  which  they  were 
placed,  however  uncomfortable,  for  several  minutes. 

Sensory  phenomena. — There  appeared  to  be  complete  absence 
of  sensation  ;  patient  would  let  wasps  sting  him  and  exhibit  no 
sign.  Patient's  father  informed  me  that  this  condition  had 
existed  for  ten  months  past  at  the  very  least  ;  about  nine  months 
ago  a  medical  man  who  was  consulted  tried  the  effect  of  a  very 
strong  electric  current,  but  failed  to  elicit  any  sign.  Sticking  a 
pin  into  the  patient's  legs,  arms,  abdomen  and  face,  and  executing 
the  strongest  possible  nerve  frictions  stimultaneously  on  both 
internal  plantar  nerves,  both  median  nerves  in  the  hands,  cervical 
nerves  on  both  sides,  and  the  umbilicus,  seemed  to  produce  no 
impression  whatever. 

The  eyes,  as  mentioned  already,  always  looked  downwards,  and 
patient  did  not  move  them  upwards  or  sideways  when  told  to 
do  so.  Patient  could  apparently  see  quite  well,  and  got  out  of  the 
way  of  chairs,  &c.,  and  he  soon  learnt  to  take  up  the  proper 
initial  position  for  his  exercises.  The  pupils  were  somewhat 
dilated,  and  reacted  normally  to  light ;  the  ophthalmoscopic  ex- 
amination was  negative.     The  hearing  was  apparently  normal. 

Motor  functions. — There  was  general  weakness  of  all  the 
muscles.  Patient  walked  slowly,  and  only  his  left  arm  swung 
meanwhile  ;  be  preferred  using  the  left  arm  in  preference  to  the 
right.  He  could  lift  up  a  chair  and  move  it  from  one  place  to 
another  when  told  to  do  so. 

In  spite  of  the  fact  that  sensation  appeared  to  be  wanting, 
patient's  walk  was  normal  excepting  for  slowness.  He  could 
walk  to  and  from  his  house  to  mine  every  day  ;  the  distance  was 
about  five  miles  and  took  him  four  hours.  He  declined,  however, 
to  walk  all  this  at  a  stretch  ;  every  mile  or  so  he  would  stop  for 
fifteen  minutes,  and  could  not  be  made  to  go  on  without  a  great 
deal  of  persuasion.  He  walked  continually  at  precisely  the  same 
rate,  and  did  not  change  even  when  told  to  walk  more  quickly. 
He  showed  no  ataxic  symptoms  while  executing  his  exercises. 

There  was  great  stiffness  of  the  muscles  of  the  neck.    Patient 


DISEASES  OF  THE  NERVOUS  SYSTEM  417 

could  not  be  induced  to  move  his  head  either  upwards,  down- 
wards, or  sideways ;  the  sterno-mastoids  were  hard  and  con- 
tracted, and  the  head  could  hardly  be  extended  backwards  on 
the  cervical  vertebra-  in  consequence.  His  food  had  to  be  cut  up 
for  liiui,  as  he  was  unable  to  use  a  knife  and  fork.  When  eating 
he  opened  his  jaws  very  little,  and  masticated  very  slo^vly ;  he  had 
to  be  told  every  few  minutes  to  take  another  mouthful,  or  he 
would  stop  altogether.  The  masseter  muscles  were  hard  and 
contracted.  Patient  could  not  be  induced  to  protrude  his  tongue. 
He  could  neither  be  persuaded  to  make  the  least  effort  at  shaking 
hands  nor  to  grasp  a  pen  when  placed  between  his  fingers.  After 
a  fortnight's  treatment,  however,  he  was  able  to  execute  his  active 
gymnastic  exercises  quite  well. 

The  abdominal  muscles  were  contracted.  Both  arm  and  leg 
muscles  exhibited  spasticit}'  during  passive  movements  at  their 
joints. 

Beflexes. — Swallowing  proceeded  slowly.  Defalcation:  Patient 
was  given  castor  oil  each  night,  and  during  the  next  morning  was 
told  to  go  to  the  closet,  which  he  sometimes  did ;  but  on  other 
occasions  he  did  not  move,  nor  go  of  his  own  accord  later  on.  A 
great  deal  of  straining  was  needed  to  effect  a  motion,  and  what 
passed  was  in  small,  round,  hard  lumps.  Micturition  was  normal, 
but  the  urine  was  thick  and  darker  coloured  than  normal.  He 
never  passed  urine  or  fieces  into  his  ciothos-  Patient's  father  ran 
short  of  medicine  six  days  before  coming  to  see  me,  and  his 
son  had  not  had  a  motion  during  the  week  preceding  the  first 
application  of  the  manual  treatment. 


Other  reflexes  : — 

Ri.nlit. 

Left. 

Plantar  reflex 

no 

no 

Kellgren's  plantar  sign 

no 

no 

Cremasteric  reflex      . . 

no 

no 

-Abdominal  reflex 

yes 

yes 

Epigastric  reflex 

yes 

yes 

Tendo  Achillis  jerk    , 

yes 

yes 

Ankle  clonus  ... 

•3  or  4  jerks 

5  or  6  jerks 

Patellar  jerk 

exaggerated 

.     exaggerated, 

althougli  not  quite  so 

much  as  on  the  right  side 

Knee  clonu.s    ... 

no 

no 

Adductor  jerk  .. 

no 

no 

Gluteal  reflex  . . 

no 

no 

Tendon  jerks  in  arm  . . 

no 

no 

27 

4i8     ELEMENTS  OF  KELLGREK'S    MANUAL    TREATMENT 

Patient's  sleep  was  (jiiite  good.  There  was  no  trophic  disturli- 
ance  beyond  some  wasting  of  tlie  muscles.  There  were  no  ulcers 
anywhere. 

Patient's  appetite  was  poor.  He  vomited  every  day  ;  every 
now  and  then  this  would  get  worse  for  a  period  of  about  two 
weeks,  during  which  he  would  vomit  after  every  meal.  Tlie 
lungs  and  heart  were  healthy.  The  pulse,  after  patient  had  sat 
still  for  twenty  minutes,  was  60  per  minute.  There  was  no 
arterio-sclerosis. 

Treutincnt. 

(1)  Sitting  head  exercise,  including  fronto-nasal  running 
vibration,  PP,  bitemporal  movement,  PP,  head  rotation  externall}', 
PP,  internally  PP ;  head  extension  backwards,  AR,  flexion  for- 
wards, PR  ;  jaw  opening,  AR  ;  closing,  PR. 

(2)  Reach  grasp  standing  head  fiexion,  PR,  extension,  AR, 
cervical  nerve  frictions,  PP. 

(3)  Reach  grasp  stoop  fall  standing  double  elbow  Hexion  and 
extension,  PA,  executed  with  shoulder  hacking,  PP. 

(4)  Forwards  lying  back  exercise,  PP. 

(6)  Ride  sitting  alternate  rotation,  AR,  nnging,  PP. 

(6)  Heave  lean  standing  chest  expansion,  PA. 

(7)  Heave  grasp  standing  chest  clapping,  side  shaking,  PP. 

(8)  Stretch  stride  standing  bending  forwards,  PA. 

(9)  Stretch  grasp  standing  drawing  forwards,  PP,  subcostal 
shaking,  PP,  abdominal  intercostal  nerve  frictions,  PP. 

(10)  Half  lying  double  leg  rolling,  PP,  flexion,  PA,  extension, 
AR ;  leg  nerve  frictions,  PP. 

(11)  Half  lying  stomach  exercise,  subdiaphragmatic  suction, 
PP,  practising  deep  respiration,  PA  ;  prostate  gland  frictions,  PP. 

In  addition,  patient  sometimes  received  frictions  simul- 
taneously on  both  internal  plantar  nerves,  both  median  nerves  at 
the  base  of  the  thumb,  the  anterior  branches  of  the  cervical  nerves 
on  both  sides,  and  the  umbilicus.  The  use  of  laxatives  was 
prohibited. 

Progress. — July  14. — Patient  did  what  he  was  told  to  do  more 
quickly  than  before,  and  also  moved  more  quickly  from  to-day 
onwards.  After  his  head  exercise  his  mouth  seemed  full  of  thick 
mucus,  but  he  could  not  be  persuaded  to  spit  it  out,  and  would 
not  allow  it  to  be  removed  by  a  handkerchief. 

July  25  to  August  4. — Treatment  interrupted. 


DISEASES  OF    THE  NERVOUS   SYSTEM  419 

August  10. — Patient's  intelligence  slowly  improving.  No 
vomiting.     Appetite   normal.     Motion  every  other  day. 

September  13. — I  had  tried  at  intervals  during  the  last  month 
to  make  patient  vprite  his  name,  but  did  not  succeed  until  this 
day.  After  very  much  persuasion  on  my  part  he  v/rote  it,  and 
after  being  ordered  continually  for  about  five  minutes  to  pronounce 
it,  he  managed  to  do  so  in  a  whisper. 

September  15. — After  being  asked  to  v/rite  "  yes"  or  "  no  "  as 
to  whether  he  felt  better,  patient  wrote  down  (in  Swedish):  "I 
am  better  now,"  signing  his  name  after  the  answer.  He  required 
much  less  persuasion  than  on  the  previous  day,  and,  after 
being  ordered  continually  for  about  five  minutes,  was  able  in  a 
whisper  to  repeat  what  he  had  written.  During  the  evening  of 
the  same  day  his  father  asked  him  to  write  down  why  he  did  not 
speak.  He  wrote  (in  Swedish) :  "  Of  course  it  is  because  of  the 
cramp." 

September  16. — Patient  at  length  understood  and  carried  out 
the  order  to  spit  out  into  a  test  tube  the  thick  mucus  from  his 
mouth  that  collected  after  head  exercise.  The  discharge  was  foul- 
smelling,  very  thick,  and  yellowish  in  colour.  It  did  not  either 
this  day  or  at  any  subsequent  date  give  the  cerebro-spinal  fluid 
reaction  with  Fehling's  solution  or  acetic  acid  (see  p.  186). 

September  19. — Patient  read  aloud  a  paragraph  of  a  news- 
paper after  a  good  deal  of  persuasion  before  and  during  the 
performance. 

Patient  finished  treatment  on  September  27,  190'2.  Owing  to 
my  temporary  absence  I  did  not  see  him  until  October  6. 

Examination. — General  condition  much  improved.  He  could 
stand  and  walk  straighter.  He  could  look  up  at  the  ceiling  so 
that  the  central  line  of  vision  formed  an  angle  of  4.5°  with  the 
ground.  His  expression  was  more  intelligent.  He  would  get  up, 
walk  about,  and  sit  down  again  by  himself.  No  cataleptic 
symptoms  were  left.  The  face  was  less  flushed,  the  sterno- 
mastoids  not  so  prominent.  Patient  sometimes  talked  in  a 
low  voice  spontaneously,  and  generally  answered  when  spoken  to. 

Sensory  phenomena. — Patient  could  feel  stimuli,  such  as  a  light 
tap,  on  hands  and  feet  ;  if  asked  beforehand  to  say  "  now  "  when 
feeling  it,  he  did  so,  the  interval  elapsmg  before  his  doing  so 
varying  from  one  to  four  seconds.  He  could  feel  a  pin-prick  on  the 
legs,  arms,  and  trunk,  but  not  a  light  tap.     His  face  contracted 


420     ELEMENTS   OF   KELLGREN'S    MANUAL    TREATMENT 

as  if  from  pain  during  hard  nerve  frictions  on  different  parts  of 
the  body,  and  on  being  asked  whether  the  manipulation  hurt, 
he  answered  "  Yes." 

The  pupils  were  less  dilated,  and  reacted  normally  to  light. 

Motor  functions. — All  his  muscles  were  stronger.  Patient 
could  walk  more  quickly  ;  he  walked  from  his  home  to  the  place 
of  treatment  in  two  and  a  balf  hours.  He  was  able  to  move  his 
head  fairly  freely.  He  could  sometimes  be  induced  to  cut  up  his 
own  food  with  a  knife  and  fork.  He  masticated  more  quickly, 
and  did  not  need  to  be  reminded  to  go  on  eating.  The  sterno- 
mastoids  and  masseters  were  less  contracted.  The  tongue  could 
be  protruded,  although  tremulously.  Patient  shook  hands  when 
told  to  do  so.  He  had  of  late  been  writing  a  few  letters,  and 
during  this  morning,  quite  spontaneously,  wrote  a  letter  of  four 
pages  to  a  friend.  The  handwriting  was  quite  clear,  the  sentences 
quite  well  framed  and  with  correct  punctuation. 

Reflexes. — Swallowing  slightly  better.  Deftecation  :  motion 
every  daj'. 

Other  reflexes  : — 

Hight.  Left. 

Plantar  reflex     ...  ...         ...         ...            no             .  •          .,         no 

Kellgren's  plantar  sign  ...          ...             no                          ...         no 

Cremasteric  reflex  ...         ...         ...            no             ...         ...         no 

Abdominal  reflex 
Epigastric  reflex 
Tendo  Achillis  jerk 
Ankle  clonus 

Patellar  jerk        ...         

Knee  clonus        ...  ...         ...         ...             no                           ,,           no 

Adductor  jerk      ...  ...          ...             no                                      no 

Gluteal  reflex      ...  ...          ...          ..               no               ..           .            no 

Tendon  jerks  in  arm  ...         ...         ...             no              ...          .  .         no 

Patient's  intelligence  had  improved  ;  occasionally  he  laughed. 

Patient's  appetite  was  better,  and  he  was  no  longer  troubled 
with  vomiting.  The  pulse,  after  he  had  sat  still  for  ten  minutes, 
was  72  per  minute. 

Bulbar  Paralysis. 

Mrs.  H.,  aged  .52,  came  under  the  manual  treatment  on 
March  6,  1899. 

History  of  present  illness. — About  March,  1897,  she  found 
that  speech  was  a  little  difScult.  It  gradually  became  more  so, 
and  then  regurgitation  of  the  food  into  the  nose  occurred.  No 
cause  could   be   assigned.      Patient  had    however,  become  very 


yes 

yes 

yes 

yes 

no 

yes 

no 

no 

exaggerated     . 

mark( 

DISEASES   OF  THE  NERVOUS  SYSTEM  4^1 

weak  and  of  low  vitality  about  two  and  a  half  years  previously 
in  consequence  of  tlie  death  of  one  of  the  members  of  her 
family.  Medical  aid  was  not  sought  for  some  time,  but  as 
the  symptoms  become  progressively  worse,  speech  and  swallow- 
ing becoming  more  and  more  difficult,  a  medical  man  was  con- 
sulted, who  diagnosed  bulbar  paralysis.  This  diagnosis  was 
subsequently  confirmed  by  several  other  medical  men.  During 
May,  1898,  patient  was  told  that  her  condition  was  hopeless,  and 
that  no  improvement  could  be  expected  from  any  remedy  what- 
soever. From  then  until  March,  1899,  she  had  been  trying 
massage,  baths,  &c.,  but  all  to  no  purpose  ;  nothing  seemed  to 
effect  the  slightest  amelioration. 

On  March  6  I  was  called  in. 

Examination. — The  condition  was  well  advanced.  The  face 
was  mask-like  and  expressionless ;  the  mouth  was  half  open, 
and  saliva  ran  from  it  continually.  There  was  complete  facial 
paralysis  on  both  sides  ;  the  lips  could  not  be  moved  ;  the  lower 
lip  hung  down.  The  tongue  was  nearly  paralysed,  only  slight 
movements  forwards  and  backwards  being  possible.  Speech 
was  almost  impossible  ;  a  few  words  like  "  Mamma  "  could  be 
pronounced  with  great  difhcuity,  but  otherwise  patient  could 
only  utter  a  few  disarticulate  sounds  and  grunts.  Patient  could 
not  swallow  the  saliva  unless  very  much  accumulated  in  the 
back  of  her  mouth.  Only  liquid  food  (eggs  beaten  up  in  milk) 
had  been  taken  for  some  months  past,  patient  not  daring  to  try 
and  swallow  anything  solid  or  semi-solid. 

There  were  no  fibrillary  tremors  of  the  face,  but  there 
were  some  of  the  tongue. 

The  general  condition  of  the  patient  was  one  of  considerable 
weakness.  The  arms  were  more  affected  than  the  legs ;  any 
communication  the  patient  had  to  make  was  written  by  her. 
She  was  only  able  to  write  slowly  and  with  tremors  in  the  arm, 
so  that  what  she  did  write  could  only  be  read  with  difficulty. 

Treatment. 

(1)  Sitting  head  exercise,  PP,  including  strong  vibration  over 
the  medulla ;  larynx  and  trachea  shaking ;  frictions  on  the  facial, 
superior  and  inferior  laryngeal,  lingual,  hypoglossal,  and  glosso- 
pharyngeal nerves,  PP. 


422     ELEMENTS  OF    KELLGREN'S    MANUAL    TREATMENT 

(2)  Reach  grasp  standing  bead  flexion,  PK,  extension,  AR, 
cervical  nerve  frictions,  PP. 

(3)  Forwards  lying  back  exercise,  PP. 

(4)  Sitting  arm  exercise,  PP,  AR,  &c. 

(5)  Heave  grasj)  standing  chest  clapping,  PP,  side  shaking, 
PP. 

(6)  Half  lying  leg  rolling,  PP,  flexion,  AR,  extension,  AR  ; 
leg  nerve  frictions,  PP. 

(7)  Half  lying  stomach  exercise,  PP. 

(8)  Walk  standing  double  arm  circling,  breathing,  PA. 
March  22. — Some  tremors  were  felt  below  the  eyes. 

March  29. — Some  movement  of  the  facial  muscles  had  re- 
turned. Patient  could  swallow  a  little  better,  and  the  word 
"  Mamma  "  could  be  pronounced  a  little  more  clearly. 

April  10. — Some  tremors  in  the  soft  palate  were  felt.  All 
the  muscles  of  the  face  which  formerly  were  quite  paralysed 
were  able  to  move  again,  although  not  yet  to  their  normal  extent. 

April  20. — Movement  in  the  soft  palate  commenced,  and  was 
visible.  The  food  no  longer  regurgitated  through  the  nose. 
The  facial  muscles  were  nearly  normal  in  their  movements,  and 
the  speech  was  slightly  better. 

May  23. — The  treatment  had  to  be  interrupted  until  July  1. 
The  improvement  was  still  being  maintained,  although  slowly. 
The  soft  palate  moved  better,  the  voice  was  better,  and  tremors 
had  begun  in  the  larynx.  The  swallowing  was  a  little  easier, 
and  the  saliva  came  in  far  less  quantity.  The  general  condition 
was  stronger. 

July  1. — Patient's  condition  had  declined  a  little  since 
May  23,  and  her  speech  had  become  worse  again.  The  facial 
muscles,  however,  had  not  lost  their  tone  or  any  of  their  power. 

August  30. — Patient's  condition  since  July  1  had  undergone 
hardly  any  perceptible  change  ;  if  anything  a  very  slight  improve- 
ment had  taken  place,  as  the  amount  of  saliva  had  gradually 
diminished  during  the  last  month.  The  relatives  of  the  patient 
did  not  wish  her  to  continue  the  treatment,  as  they  thought  it 
could  not  do  her  any  good.  Against  my  advice,  and  also  that  of 
my  colleague.  Dr.  A.  Moller,  she  went  home. 

I  heard  during  the  course  of  the  next  six  months  that  a 
change  for  the  worse  had  set  in,  and  that  after  she  left  my 
hands  the  course  of  the  disease  was  steadily  downhill.     Patient 


DISEASES   OF    THE  NERVOUS  SYSTEM  423 

continued  to  become  worse,  and  her  food  liad  to  be  administered 
by  means  of  a  tube  ;  during  May,  1900,  she  died  from  involve- 
ment of  the  respiratory  centres. 

Disseminated  Cerebro-Spinal  Sclerosis. 

K.  J.,  aged  "27,  occupation  tailor,  came  under  the  manual 
treatment  on  July  1,  1899. 

History  of  present  illness. — Patient  denied  syphilis.  He  said 
that  he  had  been  somewhat  nervous  all  his  life,  but  not  to  such 
a  degree  as  to  prevent  his  going  through  compulsory  military 
service  some  years  previously.  He  definitely  attributed  his  illness 
as  the  result  of  a  fall  off  a  bicycle  in  May,  1H96  ;  in  consequence 
of  his  machine  slipping  he  was  thrown  off,  and  he  remembered 
receiving  a  severe  blow,  which  caused  him  great  pain  in  the 
head  and  left  side,  and  was  followed  by  loss  of  consciousness. 
After  a  few  minutes  he  regained  his  senses,  but  felt  very  queer. 
The  accident  happened  quite  close  to  his  home,  and  he  walked 
home  the  rest  of  the  way  (about  100  yards).  He  felt  very  shaken 
and  queer  for  an  hour  on  arriving  home,  but  then  felt  better 
again.  He  did  not,  however,  altogether  recover,  and  found 
when  trying  to  bicycle  again  that  he  was  shaky,  had  dif&cLilty 
in  keeping  his  balance,  and  had  to  ride  in  the  middle  of  the 
road  ;  if  he  approached  the  side  where  the  ditch  was  he  had  to 
stop,  or  would  have  ridden  into  it.  He  likewise  found  that  he 
had  difficulty  in  walking.  He  could  not  walk  as  quickly  as 
before,  neither  could  he  bicycle  at  more  than  half  his  usual 
speed. 

His  strength  gradually  left  him,  and  in  the  left  leg  pain  began 
to  be  felt ;  this  became  worse  and  worse,  and  he  walked  with  still 
more  difficulty,  leaning  over  to  the  left  side.  Early  in  1897  he 
found  difficulty  in  keeping  his  balance  when  walking  in  the  dark. 
Early  in  1898  he  noticed  that  his  legs  began  to  shake  when 
engaged  in  any  movement  requiring  exertion,  and  later  on  his  left 
arm  began  to  do  the  same.  By  August,  1898,  these  tremors 
appeared  during  such  ordinary  movements  as  walking,  and  they 
had  also  begun  in  his  right  arm  and  head. 

About  Christmas,  1898,  patient  began  to  experience  waves  of 
heat  passing  through  his  body  ;  these  were  specially  marked  in 
his   toes   and   hands.     After  three  weeks  of  this,  waves  of  cold 


424     ELEMENTS    OF  KELLGREN'S   MASUAL    TREATMENT 

sensation  came  on  and  in  time  replaced  the  waves  of  heat.  His 
general  condition  steadily  became  worse,  and  he  said  he  had  an 
attack  of  influenza  in  March,  1899,  which  made  him  very  much 
worse  in  a  few  days.  So  far  he  had  been  able  to  do  a  good 
deal  of  work  (although  nothing  very  fine),  but  now  he  had  to 
stop.  Great  pain  appeared  in  the  legs,  and  he  shook  very  much 
when  walking  or  moving  his  legs. 

In  April,  1899,  he  sought  advice  for  the  first  time; '  his  medical 
man  recommended  electricity,  and  he  was  treated  daily  with  it  for 
seven  weeks,  from  the  beginning  of  April  to  the  end  of  May. 
This,  however,  made  him  still  worse.  At  the  end  of  the  time  his 
physician  told  him  that  he  had  spinal  cord  disease  and  was  in- 
curable. Patient  then  went  to  Dr.  Engstrand,  (the  head  medical 
man  in  Jonkoping),  who  diagnosed  disseminated  cerebro-spinal 
sclerosis,  and  told  patient  that  his  only  chance  was  to  try  the 
manual  treatment. 

Examination. — July  1,  1899  (by  Dr.  A.  ^Nloller  and  myself). — 
Patient  walked  with  great  difficulty,  and  was  unable  to  get  along 
without  the  help  of  a  stick.  He  kept  his  feet  wide  apart,  the 
lines  described  by  his  heels  being  about  one  and  a  half  to  two 
feet  apart,  his  knees  quite  straight  and  his  trunk  forwards, 
with  his  eyes  fixed  on  the  ground.  He  often  reached  with  the 
other  hand  (the  one  not  holding  the  stick)  for  support  from  chairs, 
tables,  &c.  When  walking  marked  volitional  jerks  could  be  seen 
in  his  head,  both  arms,  and  both  legs.  His  speech  was  slow, 
monotonous  and  syllabic  ;  his  face  moved  but  little  when  he 
spoke. 

Sensory  functions. — Patient  complained  of  a  general  feeling  of 
cold,  which  occasionally  seemed  to  pass  over  him  in  waves.  A 
feeling  of  cotton  wool  under  his  feet  had  been  present  since  May, 
1899.  He  did  not  suffer  greatly  from  pain  ;  when  present  it  was 
located  to  a  region  in  the  lower  limbs  corresponding  to  the  ex- 
ternal cutaneous  nerves.  There  was  continual  headache.  The 
muscular  sense  was  diminished. 

Eye  symptoms.—  Patient  complained  that  objects  continually 

'  The  fact  that  no  advice  was  sought  until  this  date  must  appear  strange  to 
many  of  my  readers.  The  explanation  is,  however,  that  in  Sweden  in  conse- 
quence of  the  small  population  (about  28  per  square  mile)  and  the  small  number 
of  towns,  persons  living  in  the  country  are  sometimes  distant  thirty  miles  or  more 
from  the  nearest  medical  man,  and  that  communication  is  frequently  only  by  very 
bad  roads. 


DISEASES   OF   THE   NERVOUS  SYSTEM  423 

seemed  to  dance  in  front  of  him,  then  there  was  a  pause  after 
which  they  danced  again.  Patient  had  not  anjr  great  difficulty  in 
reading,  although  he  said  that  the  print  danced  in  front  of  him. 
Nystagmus  was  present.  The  left  eye  reacted  less  to  light  than 
the  right  one.     The  reaction  to  accommodation  was  fairly  good. 

Hearing,  taste  and  smell  were  nornaal  as  far  as  could  lie  judged. 

Motor  functions. — Reflexes. — Swallowing  was  normal.  Mictur- 
ition :  there  was  difficulty  in  starting  the  stream,  and  patient 
sometimes  had  to  tr}'  five  minutes  Ijefore  he  could  get  it  to  start, 
and  at  first  it  came  in  drops.  There  was  also  some  difficulty  in 
keeping  the  mine  ;  this  was  first  noticed  after  the  electricity 
treatment.  Defascation :  there  was  a  motion  generally  every 
two  days,  although  occasionally  three  days  elapsed,  and  there  was 
difficulty  in  getting  it  to  start.  There  was  no  ankle  or  knee 
clonus  on  either  side  ;  patellar,  cremasteric  and  abdominal  reflexes 
were  slightly  present  on  the  right  side.  None  of  these  reflexes 
were  present  on  the  left  side. 

Voluntary  movements. — The  walk  has  been  described.  All 
voluntary  movements  were  accompanied  by  volitional  jerks,  which 
absolutely  ceased  when  the  former  ceased,  and  which  became 
intensified  during  duplicate  movements.  Patient  could  eat  with  a 
knife  and  fork  until  April,  but  then  gave  up  doing  so  as,  in  conse- 
quence of  the  volition  jerks,  he  was  unable  to  cut  his  food  and 
unable  to  convey  it  to  his  mouth.  He  now  ate  with  a  spoon,  and 
could  only  use  his  left  hand  in  doing  so.  He  could  hardly  sew 
at  all  with  his  left  hand,  as  the  fingers  moved  over  one  another  in 
a  rubbing  kind  of  way  when  he  tried  ;  he  could  not  even  hold  a 
needle  in  his  right  hand.  On  being  asked  to  protrude  the  tongue, 
he  did  so  with  jerks  of  that  organ,  and  it  exhibited  fibrillary 
twitch ings,  especially  round  the  edges. 

Coordination. — The  Eomberg  symptom  was  present,  the 
patient  swaying  for  a  few  seconds  first.  With  the  eyes  kept  open 
he  swayed  a  good  deal,  but  did  not  fall.  He  could  not  walk  in  a 
straight  line,  but  deviated  considerably.  With  his  eyes  closed  he 
could  not  Ijring  his  finger  tips  together.  He  wrote  with  his  left 
hand  with  difficulty. 

Patient's  memory  was  not  so  good  as  it  used  to  be.  He  was 
very  thin,  weighing  -59  kilos,  in  ordinary  clothes. 

There  was  a  C-shaped  scoliosis  with  the  convexity  to  the 
right,  and  the  right  shoulder  was  higher  than  the  left. 


426      ELEMENTS   OF    KELLGREN'S   MANUAL    TREATMENT 

The  sexual  power  had  been  weak  for  a  year  or  more,  and  since 
April,  1899,  it  had  been  quite  lost ;  no  erection  ever  took  place  any- 
more. 

Treatment. 

(1)  Eeach  grasp  step  standnig  knee  Hexion  and  extension,  PA, 
sacral  beating,  PP. 

(2)  Stretch  grasp  standing  drawing  forwards,  PP,  vibrations 
over  the  bladder,  PP. 

f3)  Loin  lean  stride  standing  alternate  rotation,  AR,  ringing, 
PP. 

(4)  Forwards  lying  back  exercise,  PP. 

(5)  Stretch  side  lying  running  nerve  frictions,  PP,  leg  lifting, 
AE,  pressing  down,  PR. 

(6)  Heave  grasp  standing  chest  clappmg,  PP,  side  shaking, 
PP. 

(7)  Stretch  stride  standing  l_)ending  forwards,  PA. 
fn)  Stride  sit  kneeling  raising,  AE. 

(9)  Standing  vertebral  column  stretching  with  AR  at  the 
patient's  head. 

(10)  Half  lying  stomach  exercise,  PP. 

On  September  30,  1899,  patient  left,  saynig  that  he  would 
come  back  in  three  days ;  he  did  not,  however,  do  so  until 
December  18,  and  in  consequence  no  systematic  examination  was 
made.  Patient,  however,  told  me  afterwards  that  he  improved 
during  the  time  of  treatment ;  he  could  walk  more  easily  and  did 
not  need  to  use  his  stick  so  much  ;  he  could  even  walk  a  few 
yards  without  it.  He  said  that  the  jerks  on  voluntary  movement 
were  less  in  amount. 

On  December  13  the  patient  returned  to  continue  the  treat- 
ment. He  was  in  every  respect  worse  than  when  he  left  on 
September  30.  Owing  to  temporary  illness  on  my  part  I  could 
not  make  the  examination  until  January,  1900.  During  that 
time,  however,  the  treatment  was  administered  by  my  colleague, 
Dr.  A.  Moller.  Patient  was  already  better  than  on  December  13. 
He  said  that  three  days  after  leaving  off  the  manual  treatment 
in  September,  he  began  to  feel  worse,  walk  worse,  &c.  ;  he  got 
steadily  worse  until  December  13  ;  his  condition  then  remained 
stationary  for  two  days,  and  then  he  felt  better  again.  From 
December  24  to  2Q  he  received  no  treatment,  and  on  the  26th 


DISEASES  OF   THE   NERVOUS    SYSTEM  427 

he  felt  that  he  was  again  getting  worse.  Since  then,  undergoing 
the  treatment  all  the  time,  he  had  progressed  steadily'. 

Examination. — Patient's  walk  was  much  worse  than  in 
September ;  he  had  great  difficulty  in  walking  at  all,  even  with 
tiie  help  of  a  person  on  one  side  holding  him  up,  and  the  use 
of  a  stick  in  the  other  hand.  He  was  lodging  at  a  house  about 
•200  yards  from  my  own,  and  to  walk  that  distance  took  at  least 
ten  minutes.  In  case  of  windy  weather,  patient  had  frequently 
to  stop  or  he  would  be  blown  over,  so  bad  was  his  ability  to 
balance.  He  walked  with  his  knees  straight  and  his  feet  wide 
apart,  hardly  lifting  his  heels  at  all ;  his  arms  were  spread  out  and 
caught  hold  of  doors,  tables,  chairs,  &c.,  to  assist  his  balance, 
and  his  whole  body  exhibited  marked  volitional  jerks  in  trunk, 
liiubs,  and  head.  Patient's  speech  was  still  slower,  more  monot- 
onous and  monosyllabic,  and  the  corners  of  the  mouth  twitched 
while  he  talked. 

Sensory  functions. — -Patient  had  been  subject  to  severe  light- 
ning pains  in  his  arms  and  head  and  lower  limbs,  specially  the 
latter.  He  had  continual  headaches,  which  were  so  bad  during 
December  before  he  came  to  be  treated  that  he  could  hardly  see 
at  all.  There  was  impaired  sensation  in  the  feet ;  patient  con- 
tinually felt  as  if  he  were  walking  on  cotton  wool.  When 
receiving  forwards  lying  running  nerve  frictions  he  felt  as  if  they 
were  being  administered  through  a  blanket  which  deadened  sen- 
sation. There  was  a  continued  feeling  of  formication  in  the  upper 
dorsal  region  and  in  the  pectoral  muscles.  The  mouth  and  nose 
felt  numb;  there  was  considerable  anaesthesia  of  the  fifth  nerve; 
very  little  sensation  was  felt  on  pinching  hard  the  skin  of  the  face. 
His  feet  and  legs  were  always  cold.  There  was  no  sensation  in 
the  feet  during  popliteal  nerve  frictions,  and  none  in  the  spine 
during  cervical  nerve  frictions.  There  was  considerable  diminu- 
tion in  the  muscular  sense. 

Eye  symptoms. — Nystagmus  was  very  well  marked,  and 
patient  said  that  objects  danced  more  than  they  used  to.  The 
right  eye  reacted  very  little  to  light,  and  the  left  not  at  all ;  the 
reaction  of  both  to  accommodation  was  not  good.  Patient  could 
hardly  read  at  all.  There  was  no  achromatopsia.  Patient's  taste 
was  not  so  good  as  it  used  to  be  ;  his  hearing  and  smell  were 
apparently  normal. 

Motor  functions — Eefiexes. — Micturition  :  there  was  difficulty 


428     ELEMENTS   OF   KELLGREN'S   MANUAL   TREATMENT 

in  getting  the  stream  to  start ;  patient  often  tried  eight  minutes 
without  success,  and  then  he  would  stop  and^try  again  later  on. 
When  he  did  succeed,  the  stream  at  first  only  came  in  drops.  He 
had  partial  incontinence  sometimes  ;  he  always  felt  it  coming  on, 
and  then  could  not  hold  his  water  for  more  than  half  a  minute  or 
so.  Defjecation  :  rectal  evacuation  took  place  about  every  three 
days,  occasionally  every  four.  There  was  considerable  difficulty 
in  getting  the  motion  to  start,  fifteen  minutes  having  often  to 
be  expended  in  efforts. 

No  ankle  or  knee  clonus,  patellar,  abdominal,  or  cremasteric 
reflexes  could  be  obtained  on  either  side. 

Voluntary  movements. — The  volition  jerks  were  much  more 
marked.  The  gait  has  been  referred  to.  During  ride  sitting 
trunk  flexion,  PR,  extension  AR,  patient  jerked  very  much  indeed  ; 
his  head  made  a  series  of  jerks  forwards  six  inches  and 
backwards  three,  and  his  gluteal  region  was  lifted  off  the  couch 
each  time  from  three  to  six  inches.  About  half-way  through 
the  first  part  of  the  exercise  patient  lost  his  balance  altogether  and 
had  to  put  out  his  hands  to  catch  hold  of  the  couch  to  support 
himself.  Patient  had  to  be  supported  while  trying  to  perform 
stretch  stride  standing,  bending  forwards,  PA.  Movements 
involving  flexion  of  the  knee-joints  could  hardly  be  done  at  all. 
An  attempt  to  perform  reach  grasp  toe  standing  double  knee 
bending,  PA,  resulted  in  the  patient  falling  almost  at  once. 
During  all  movements  of  resistance  the  whole  body  jerked  very 
much. 

Patient  used  to  feed  himself  with  his  left  hand  with  a  spoon, 
and  had  to  bend  his  head  forward  to  get  the  spoon  into  his 
mouth.  If  he  did  not  the  jerks  of  the  left  hand  were  so  great 
that  he  could  not  bring  his  spoon  up  to  his  mouth.  Even  when 
bending  his  head  forwards  the  contents  of  the  spoon  were  often 
spilt.  Patient  could  not  sew  at  all,  and  when  trying  to  cut  out 
the  scissors  wobbled  about  so  that  he  cut  all  wrong.  He  had 
great  difficulty  in  writing,  as  he  could  hardly  hold  a  pen,  due  to 
volitional  jerks  in  his  fingers. 

Coordination. — With  eyes  shut  and  feet  together  he  would  fall 
at  once  ;  with  eyes  open  and  feet  together  he  would  sway  for 
a  second  or  so  and  then  fall. 

Patient  was  very  thin  and  his  joints  were  very  supple.  When 
sitting  on  the  floor  with  his  knee-joints  fully  extended,  patient 


DISEASES   OF   THE  NERVOUS  SYSTEM  429 

could  bend  his  body  forwards  so  that  bis  mouth  touched  bis 
knees.  His  memor}'  was  worse  than  during  July.  His  speech 
has  been  described.  He  had  slept  very  badly  during  November, 
but  since  then  satisfactorily.  There  were  no  volition  jerks  when 
trying  to  go  to  sleep,  though  when  sitting  still  the  head  nodded 
to  and  fro  continually. 

The  scoliosis  was  better  and  the  shoulders  were  of  the  same 
height. 

The  pulse  while  patient  was  sitting  down  was  52  per  minute. 

The  treatment  was  about  the  same  as  before,  with  the 
addition  of  sitting  head  exercise,  PP,  and  ride  sitting  trunk 
flexion,  PP,  extension,  AR. 

Progress. — February  13,  1900. — Volition  jerks  not  so  marked. 
Patient  walked  up  a  flight  of  fifteen  steps  in  my  house,  holding 
on  to  the  bannister  on  both  sides  ;  it  was  difficult  for  him  to  do 
so,  but  his  efforts  were  successful.  He  said  that  he  could  not 
have  done  this  two  months  previously.  The  walk  was  better. 
Sensation  was  present  in  the  feet  during  popliteal  nerve  frictions. 

March  13. — With  feet  together  and  eyes  shut  patient  swayed 
for  a  few  seconds  before  falling.  The  volition  jerks  were  slightly 
less.     Patient  was  able  to  sew  and  cut  out  a  little. 

April  12. —  Patient  did  not  fall  at  all  with  his  feet  together 
and  his  eyes  shut.  There  was  less  difficulty  with  micturition ; 
a  rectal  evacuation  had  taken  place  almost  daily  during  the 
last  month.  Frictions  on  the  cervical  nerves  caused  some  slight 
sensation  down  the  spine.  The  volition  jerks  were  consider- 
ably less. 

April  20. —  Patient  had  made  very  great  progress  during  the 
last  three  weeks  as  regards  his  walk.  On  April  18  he  moved  to 
Huskvarna,  and  since  then  he  had  walked  to  and  from  my  house 
once  daily,  the  distance  between  his  house  and  mine  being  about 
two-thirds  of  a  mile. 

Patient  during  the  time  he  was  under  treatment  had  occasion- 
ally, every  fortnight  or  so,  had  a  very  bad  headache,  lasting  from 
two  to  five  days.  At  the  conclusion  of  the  headache  his  improve- 
ment was  quicker  for  the  next  few  days.  Thus  he  had  a  rather 
bad  attack  just  about  April  1  before  he  made  the  considerable 
improvement  between  that  date  and  April  20. 

May  .5. — Patient  said  that  he  had  not  walked  as  well  as  to-day 
for  the  last  fifteen  months. 


430     ELEMENTS  OF  KELLGREN'S    MANUAL    TREATMENT 

May  ].5. — An  attempt,  for  tlie  first  time,  to  get  patient  to 
perform  reach  grasp  toe  standing  double  knee  bending,  PA,  failed ; 
he  jerked  np  and  down  violently  two  or  three  times,  and  then 
would  have  fallen  if  I  had  not  held  him  up. 

May  24  to  27. — Bad  headache. 

May  28. — Some  fever. 

May  29. — Patient  said  that  he  was  able  during  the  morning 
to  stand  alternately  on  each  leg  while  putting  on  his  trousers  ;  he 
had  not  been  able  to  do  this  since  February,  1898. 

June  8. — Patient's  walk  continued  to  improve.  His  head- 
aches were  less  severe  ;  be  could  to-day  perform  reach  grasp  toe 
standing  double  knee  bending,  PA,  although  it  was  very  jerky. 

July  15. — Headaches  still  better  ;  patient  has  not  felt  as  well 
for  over  two  years. 

August  10. — Patient's  right  hand  had  so  far  recovered  that 
he  was  able  to  use  it  for  sewing  purposes  to  do  his  tailoring, 
and  while  cutting  out  the  scissors  did  not  wobble  at  all. 

September  14. — Patellar  reflex  on  left  knee  had  returned  to  a 
slight  extent.  Cervical  nerve  frictions  could  be  felt  down  the 
whole  of  the  spine  quite  well,  and  during  the  exercise  stretch  half 
lying  double  hand  and  foot  nerve  frictions,  PP,  added  about  two 
months  previously,  sensation  was  felt  through  the  whole  of  the  body. 

The  treatment  had  gradually  changed,  and  was  now  as  follows  : 

(1)  Sitting  head  exercise,  PP. 

(2)  Reach  grasp  step  standing  knee  flexion  and  extension,  PA, 
sacral  beating,  PP. 

(3)  Stretch  grasp  standing  drawing  forwards,  PP,  intercostal 
nerve  frictions  and  vibrations  over  the  bladder,  PP. 

(4)  Head  lean  arch  standing  toe  raising,  breathing,  PA. 
(.5)  Forwards  lying  back  exercise,  PP. 

(6)  Ride  sitting  trunk  flexion,  PR,  extension,  AR. 

(7)  Heave  grasp  standing  chest  beating,  PP,  side  shaking,  PP. 

(8)  Stretch  half  lying  double  hand  and  foot  nerve  frictions,  PP. 

(9)  Side  lying  running  nerve  frictions,  PP,  leg  lifting,  AR, 
pressing  down,  PR. 

(10)  Half  lying  stomach  exercise,  PP. 

(11)  Stretch  stride  standing  bending  forwards,  PA. 

(12)  Reach  grasp  toe  standing  double  knee  bending,  PA. 
October  20. — Nystagmus  only  very  slight.     Patient  could  walk 

when  the  weather  was  not  windy  as   quickly  as   any   ordinary 


DISEASES  OF    THE   NERVOUS    SYSTEM  431 

person.  He  did  not  jerk  «o  much  when  performing  his  gymnastic 
exercises ;  this  was  specially  noticeable  as  regards  bis  arms. 
Two  days  ago  he  left  off  eating  with  a  spoon,  and  now  ate  with  !i 
knife  and  fork.  The  tongue  trembled  at  the  edges,  but  did  not 
jerk  when  patient  protruded  it. 

November  6. — Objects  did  not  dance  in  front  of  patient  any 
more,  excepting  slightly  while  reading.     There  was  no  nystagmus. 

December  8. — Slight  knee  clonus  on  left  side,  none  on  right. 
Some  ankle  clonus  on  both  sides.  Patellar  reflexes  :  left  normal, 
right  not  quite  so  marked. 

Examination. — December  20,  11)00. — Patient's  walk  much 
better ;  he  walked  from  his  house  to  mine  daily,  this  taking  him 
fifteen  to  twenty  minutes,  the  distances  being  about  two-thirds  of 
a  mile  ;  even  when  it  blew  hard  he  could  get  along  fairly  well. 
He  preferred  walking  with  the  aid  of  a  stick,  though  the  latter 
was  by  no  means  a  necessity.  When  walking  he  bent  his  knees 
and  lifted  his  heels  off  the  ground,  and  placed  his  feet  fairly  well 
in  front  of  one  another,  the  lines  described  by  his  heels  being  about 
four  inches  apart.  With  the  help  of  a  stick  he  could  place  his  feet 
when  walking  so  as  to  describe  a  contmuous  straight  line ;  he 
could  not,  however,  do  this  without  a  stick.  Some  slight  vohtional 
jerks  were  visible  in  his  legs  while  walking,  but  none  in  his  arms. 
Patient's  speech  was  quicker  and  more  lively :  he  raised  and 
dropped  his  voice,  and  generally  speaking  talked  like  an  ordinary 
person. 

Sensorij  fiiitctivns. — No  lightning  pains  experienced,  but  pain 
was  often  felt  in  the  ankle-joints,  lumbar  region,  side  of  abdomen 
and  calves.  The  headache  was  much  better.  For  the  last  three 
weeks  or  so  great  waves  of  heat  had  been  passing  over  patient's 
body,  similar  to  those  of  1898,  as  already  mentioned.  The  feet 
and  legs  were  now  always  warm.  There  was  sometimes  a  feeling 
of  formication  in  the  back  of  the  head  and  the  fingers  and  heels. 
The  fifth  nerve  appeared  to  be  normally  sensitive.  There  was  no 
numbness  anywhere  excepting  to  a  slight  extent  under  the  feet, 
and  this  was  only  perceived  during  nerve  frictions  on  them.  The 
muscular  sense  was  quite  good.  Sensations  in  the  whole  body 
were  felt  on  receiving  stretch  half  lying  double  hand  and  foot 
nerve  frictions,  PP,  and  on  receiving  cervical  nerve  frictions, 
and  there  was  sensation  in  the  feet  during  sciatic  and  popliteal 
nerve  frictions.  The  sensory  nerve  conductivity  in  general  seemed 
quite  good. 


432  ELEME.\TS   OF    KELLGREN'S   MANUAL    TREATMENT 

Eye  sjiaptoiuh. — No  nystagmus  ;  patient  said  that  objects  did 
not  dance  at  all  in  front  of  him,  nor  did  the  lines  of  a  newspaper 
during  reading,  unless  he  was  very  tired  or  had  a  bad  headache. 
The  pupils  reacted  fairly  well  to  accommodation,  but  little  to 
light.  Patient's  taste  was  normal  again,  but  his  smell  not  yet 
fully  restored. 

Motor  functions. — Ketlexes.  —  Micturition:  this  was  now 
normal  ;  there  was  never  anj'  symptom  of  incontinence  or  reten- 
tion ;  the  stream  started  at  once  on  making  the  effort.  Defse- 
cation :  there  was  no  difficulty  in  getting  the  motion  started  ;  there 
was  an  evacuation  usually  every  day,  occasionally  every  other  day. 

No  epigastric  or  abdominal  reflexes.  Kellgren's  plantar  sign 
and  ankle  clonus  (four  or  five  jerks)  present  in  equal  amount  on 
both  sides.  Patellar  reflex  :  left,  exaggerated,  followed  by  several 
jerks  at  knee-joint  and  ankle-joint ;  right,  present  but  not  quite 
to  normal  amount.  Knee  clonus :  left,  one  or  two  jerks  felt ; 
right,  there  appeared  to  be  the  beginning  of  a  jerk. 

Voluntary  movements. — While  patient  was  sitting  still,  the 
head  did  not  nod  at  all ;  when  he  walked  quickly  it  did  so  very 
slightly.  There  were  no  jerks  in  the  arm  when  patient  held  it  out 
at  right  angles  ;  the  fingers  remained  almost  immovable.  During 
a  strong  duplicate  movement  a  few  volitional  jerks  took  place 
in  the  arms.  During  ride  .sitting  trunk  flexion,  PE,  extension, 
AE,  about  twenty  small  jerks  were  given,  each  one  bringing  the 
patient  back  about  half  to  one  inch  ;  there  was  no  tendency  to  fall 
or  lose  the  balance.  I'atient  could  perform  stretch  stride  stand- 
ing bending  forwards,  PA,  quite  well  without  support.  The  only 
movements  that  caused  much  jerking  were  those  which  entailed 
contraction  of  the  quadriceps  extensor  cruris,  and  the  exercise 
head  lean  arch  standing  toe  raising,  breathing,  PA.  When  patient 
stretched  out  his  tongue  there  were  no  jerks,  but  fibrillar  twitch- 
ings  along  the  edge.  Patient  ate  with  knife  and  fork  quite  well. 
He  could  sew  with  his  right  hand.  He  could  whistle  and  smack 
his  lips.     When  speaking  his  face  moved  normally. 

Coordination. — Patient  could  walk  fairly  well  in  partial  dark- 
ness. With  eyes  shut  and  feet  together  he  swayed  a  good  deal, 
but  did  not  fall.  With  eyes  shut  and  feet  at  right  angles  he 
swayed  somewhat.  With  arms  spread  out  and  one  foot  off  the 
ground  he  could  balance  for  a  second  or  two  without  fallmg. 

Patient  said  that  he  felt  much  stronger.  He  was  still  very 
thin,  his  weight  being  61^  kilos.     He  had  been  perspiring  very 


DISEASES  OF   THE  NERVOUS    SYSTEM  433 

much  at  night  for  the  last  three  weeks,  ever  since  he  began  to 
experience  waves  of  heat  passing  over  him,  as  mentioned.  His 
memory  had  improved  during  the  year. 

The  spine  was  straight,  and  no  curvature  could  be  seen. 

The  pulse  while  patient  was  sitting  down  was  74  per  minute. 

Erections  of  the  penis  often  came  on ;  but  he  had  not  yet 
attempted  coitus. 

Patient  continued  the  treatment  under  my  colleague,  Dr. 
Harry  Kellgren.  On  March  5,  1901,  I  again  saw  him.  He  had 
continued  to  improve.  The  pupils  reacted  both  to  light  and 
accommodation,  though  better  to  the  latter.  There  were  no  skin 
reflexes.  Patellar  reflex :  left,  normal ;  right,  less  than  normal. 
Ankle  clonus,  a  very  little  on  both  sides.  A  little  knee  clonus  on 
the  left  side. 

On  April  4  Dr.  Harry  Kellgren  wrote  to  me  :  "  Patient  walks 
better ;  can  run  alone  about  seven  or  ten  steps.  He  can  do — 
Eide  sitting  falling  backwards,  breathing,  PA ;  head  lean  arch 
standing  toe  raising,  breathing,  PA  ;  stride  sit  kneeling  raising, 
AR ;  lying  double  leg  flexion  and  extension,  PA,  perfectly  steadily, 
without  assistance  and  without  the  jerks  which  he  had  before. 
There  are  no  cutaneous  reflexes  ;  the  knee  jerks  are  the  same  as 
on  December  20,  1900  ;  there  is  no  ankle  clonus.  Pupils  react  to 
light  and  accommodation." 

Subsequent  history. — Treatment  interrupted  May  7  to  June  1, 
1901.  After  that  not  very  much  improvement  took  place;  the 
improvement  by  January  3,  190'2,  can  be  summed  up  as  follows  : 
No  cotton  wool  feeling  under  the  feet.  No  volitional  jerks  in  head 
when  walking  fast.  No  knee  or  ankle  clonus.  Seminal  emissions 
again  taking  place  ;  about  once  every  three  weeks. 

On  January  3,  1902,  patient,  without  having  said  a  word 
previously,  left  off  coming  to  me  for  treatment,  as  he  had  been 
persuaded  to  try  some  new  remedy  instead.  I  have  not  seen  him 
since  that  date,  and  therefore  have  had  no  opportunity  of  making 
any  examination  as  to  his  condition. 


Spinal  Apoplexy  during  Secondary  Syphilis, 

H.  S.,  aged  51  years,  male,  came  under  the  manual  treatment 
on  January  8,  1900. 
28 


434     ELEMENTS   OF   KELLGREN'S   MANUAL   TREATMENT 

History  of  ^^rescnt  ilhiess. — During  November,  1881,  patient 
contracted  primary  syphilis,  which  was  followed  about  February, 
1882,  by  secondary  symptoms — hoarseness,  sore  throat,  ulcers  in 
the  mouth,  swollen  glands  in  the  neck,  condyloma  at  the  anus,  &c. 
During  April,  1882,  while  standing  still,  patient  was  suddenly 
seized  with  pains  in  his  back  and  twitchings  in  his  limbs ;  in 
a  few  minutes  he  felt  his  legs  giving  way,  and  he  was  obliged 
to  lie  down.  In  the  course  of  about  half  an  hour  complete  para- 
lysis of  motion  and  partial  paralysis  of  sensation  ensued  in  both 
legs,  together  with  incontinence  of  both  urine  and  faeces ;  there 
was  also  a  sense  of  constriction  round  the  abdomen.  No  medical 
aid  could  be  obtained  until  eight  days  had  elapsed,  when  patient 
had  so  far  recovered  that  he  could  walk  a  little  ;  the  medical  man 
consulted  told  him  that  his  spinal  cord  was  affected.  A  very 
slow  improvement  gradually  took  place  during  the  ensuing  two 
years.  After  that,  however,  his  condition  remained  almost 
unaltered,  in  spite  of  his  having  taken  many  different  kinds  of 
medicine,  and  having  at  intervals  tried  baths,  electricity,  and 
massage. 

Examination. — January  8,  1900. — Patient  walked  awkwardly, 
with  the  aid  of  a  stick,  and  with  his  knees  somewhat  bent ;  and 
he  had  a  foot-drop  which  caused  him  to  lift  his  feet  high  off  the 
ground  at  each  step  ("  steppage  gait").  While  walking  he  looked 
continually  as  if  he  were  on  the  point  of  falling  forwards. 

Sensori]  2^J>'£»o>ne>ta. — Patient  complained  of  lightning  pains 
in  the  course  of  both  great  sciatic  nerves,  of  more  or  less  continued 
pain  in  the  front  of  both  lower  legs  and  outer  side  of  both  thighs, 
and  of  a  sensation  of  constriction  round  the  abdomen.  There  was 
cotton  wool  sensation  under  both  feet.  There  was  partial  anaes- 
thesia of  the  feet  on  both  plantar  and  dorsal  aspects,  and  of  the 
front  of  both  lower  legs ;  in  these  areas  there  was  delayed  con- 
duction of  sensation,  sometimes  as  much  as  three  or  four  seconds 
elapsing  after  the  application  of  a  pin  prick  before  the  sensation 
was  felt.  In  the  abdomen  there  was  hyperesthesia  at  the  level  of 
the  seventh  and  eighth  intercostal  nerves,  with  slight  anassthesia 
and  delayed  conduction  below  this  area.  There  was  no  sensation 
in  the  spine  during  cervical  nerve  frictions. 

The  eyes  reacted  slightly  to  light  and  not  at  all  to  accommoda- 
tion.    Both  pupils  were  very  small. 

Motor  phenomena  : — Keflexes. — Micturition:    there   was  difti- 


DISEASES  OF  THE  NERVOUS  SYSTEM 


435 


culty   in   retaining   the   urine,  and   nocturnal   incontinence    was 
present.     Defecation :  There  was  constipation,  often  five  or  six 
days  passing  without  a  motion ;  patient  often  had  to  strain  hard 
for  twenty  to  thirty  minutes  before  he  could  get  one. 
Other  reflexes  were  as  follows  : — 


Riglit. 

Left. 

Epigastric  skin  reflex 

slight 

slight 

Abdominal  skin  reflex 

marked 

marked 

Babinsky's  sign        

marked 

marked 

Kellgren's  plantar  sign 

yes 

yes 

Teudo  Achillis  jerk 

yes 

yes 

Ankle  clonus 

10-20  jerks 

20-30  jerks 

Patellar  reflex          

exaggerated 

much  exaggerated 

Knee  clonus  ..          

5-6  jerks 

5-10  jerks 

Adductor  jerk          

yes 

yes 

Crossed  adductor  jerk 

yes 

yes 

Semimembranosus  jerk 

yes 

yes 

Semitendinosus  jerk 

yes 

yes 

There  was  general  weakness  of  all  the  muscles  of  the  lower 
limbs ;  this  was  especially  marked  in  the  anterior  tibial  muscles, 
patient  being  unable  to  flex  his  foot  to  a  right  angle,  and  in  the 
abductors  of  the  thighs  patient  being  almost  unable  when  in  side 
lying  position  to  abduct  his  leg. 

Patient  could  not  correctly  locate  the  position  of  his  feet. 
With  feet  together  and  eyes  shut,  also  with  heels  together 
but  feet  at  right  angles  and  eyes  shut,  patient  fell  at  once. 
Patient  could  not  walk  in  a  straight  line.  He  was  quite  unable 
to  stand  on  one  leg,  even  when  balancing  himself  with  his  arms. 
He  suffered  from  occasional  attacks  of  prolonged  twitching  and 
spasms  in  his  legs.  Sensation  and  motion  in  the  arms  were 
unaffected. 

Sexual  functions. — Since  the  onset  of  his  illness  patient  had 
never  had  an  erection  or  nocturnal  seminal  emission.  There  was 
atrophy  of  both  testicles,  this  being  especially  marked  in  the  case 
of  the  left  one,  which  was  hardly  three-quarters  of  an  inch  in 
its  long  diameter.     Testicular  sensation  was  lost. 

A  certain  amount  of  chronic  bronchitis  had  been  present  ever 
since  the  onset  of  the  disease.  The  lower  intercostal  spaces  were 
indrawn  on  inspiration. 


Treatment. 

The  exercises  were  changed  a  little  from  time  to  time,  but  the 
following  is  a  general  specification  : — 


436      ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

(1)  lleach  grasp  step  standing  knee  flexion  and  extension, 
PA,  sacral  beating,  PP. 

(2)  Stretch  grasp  standing  drawing  forwards,  PP,  frictions  on 
the  abdominal  intercostal  nerves,  and  shaking  over  the  bladder, 
PP. 

(3)  Ride  sitting  trunk  flexion,  PP,  extension,  AE. 

(4)  Forwards  lying  back  exercise,  PP,  leg  flexion,  PR,  raising, 
AE. 

(5)  Heave  grasp  standing  chest  clapping,  PP,  side  shaking, 
PP. 

(6)  Stretch  stride  standing  bending  forwards,  PA. 

(7)  Sit  lying  knee  extension  and  flexion,  PP,  extension,  AE, 
flexion,  PR. 

(8)  Side  lying  leg  lifting,  AE,  pressing  down,  PR,  leg  nerve 
frictions  and  side  length  hacking,  PP. 

(9)  Loin  lean  stride  standing  alternate  rotation,  AR,  ringing, 
PP. 

(10)  Head  lean  arch  standing  toe  raising,  breathing,  PA. 

(11)  Half  lying  stomach  exercise,  prostate  gland  frictions,  PP. 
Progress. — March    19. — Patient    stronger,    ^specially   in    the 

abductors  of  the  thighs ;  he  walked  more  easily.  With  feet 
together  and  eyes  shnt  he  swayed  a  good  deal,  but  did  not  fall. 
There  was  less  difficulty  in  retaining  the  urine.  There  was  no 
nocturnal  incontinence,  although  patient  was  obliged  to  get  up 
two  or  three  times  every  night  to  pass  water.  Rectal  evacuation 
took  place  every  second  or  third  day. 

May  8. — Sensation  and  conductivity  were  normal  over  the 
front  of  the  lower  leg  and  dorsum  of  foot,  and  there  was  very 
little  sensation  of  cotton  wool  under  the  feet.  The  Romberg 
symptom  was  almost  gone ;  patient  swayed  but  little  more  than 
a  normal  subject.  He  was  able  to-day,  for  the  first  time  for 
eighteen  years,  to  stand  alternately  on  each  leg  while  putting 
on  his  trousers. 

July  7. — Patient  steadily  gaining  strength.  Cervical  nerve 
frictions  felt  down  the  spine  as  far  as  the  sacrum.  Fewer  light- 
ning pains. 

September  8,  1900. — Treatment  finished. 

Examination. — Patient's  walk  better,  although  still,  but  to  a 
less  extent,  exhibiting  the  peculiarities  mentioned  on  p.  434. 

Sensor !i  phenomena. — Fewer  lightning  pains,  and  less  pain  in 


DISEASES  OF  THE  NERVOUS  SYSTEM  437 

the  feet  and  lower  legs.  No  ausesthesia  or  delayed  conduction 
anywhere.  Sensation  of  constriction  round  the  abdomen  not  .so 
pronounced ;  less  hyperaesthesia  in  the  area  of  the  seventh  and 
eighth  intercostal  nerves.  Patient  able  to  locate  the  position  of 
his  feet.     No  Romberg  symptom  (see  below). 

The  right  eye  reacted  fairly  well  to  light,  but  the  left  eye 
hardly  at  all.  Both  eyes  reacted  slightly  to  accommodation. 
When  doing  so  the  left  pupil  dilated  somewhat  irregularly.  Both 
pupils  were  larger  than  when  patient  first  came  to  me. 

Motor  phenomena. — Reflexes. — Micturition:   this  was  normal, 
except  for  a  slight  difficulty  in  retaining  the  urine.     Defaecation  : 
a  motion  took  place   every   day  or   every  other  day,    and  little 
straining  was  needed  in  order  to  effect  it. 
The  other  reflexes  were  as  follows  : — 

Epigastric  sliiu  reflex 
Abdominal  skin  reflex 
Babinsky's  sign 
Kellgren's  plantar  sign 
Tendo  Achillis  jerk 
Ankle  clonus     ... 
Patellar  reflex 

Knee  clonus     

Adductor  jerk  ... 
Crossed  adductor  jerk 
Semimembranosus  jerk 
Semitendinosus  jerk  ... 

The  anterior  tibial  muscles  and  abductors  of  thighs  were 
stronger. 

Patient  could  walk  in  a  straight  line.  With  his  arms  in 
stretch  position  he  could  balance  himself  on  one  leg  for  eight 
seconds,  and  he  could  even  do  so  for  two  or  three  seconds  with 
his  eyes  shut.  There  had  been  lio  attacks  of  twitchings  or 
spasm  for  the  last  three  months. 

Sexual  functions. — These  showed  very  little  improvement. 
No  nocturnal  emissions  occurred  ;  occasionally  a  slight  amount  of 
erection  took  place. 

The  chronic  bronchitis  had  almost  completely  disappeared. 

Infantile  Paralysis. 

In  twelve  out  of  fifteen  cases  of  this  disease  in  the  chronic 
stage  I  found  that  there  was  distinct  tenderness  or  even  pain 


Right. 

Left. 

slight 

slight 

yes 

yes 

yes 

yes 

no 

no 

no 

no 

5-10  jerks 

10-20  jerks 

normal 

exaggerated 

.      1  or  2  jerks     ... 

1  or  2  jerks 

yes 

yes 

no 

no 

yes 

yes 

yes 

yes 

43S     ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

during  frictions  over  the  kidneys  from  behind  or  over  the  renal 
plexus  in  front ;  and  almost  always  there  was  a  greater  tender- 
ness over  the  kidney  on  that  side  where  the  paralysis  was  greater. 

Case  1. 

G.  L.,  male,  aged  15^  years,  came  under  the  manual  treat- 
ment on  October  3,  1899. 

History  of  present  illness. — During  October,  1888,  patient 
was  one  day  attacked  with  shivering  and  fever,  and  about  a  day 
later  complete  loss  of  motion  in  both  legs  resulted,  sensation, 
however,  being  unimpaired.  After  three  weeks  the  right  leg 
gradually  recovered  and  became  quite  well,  but  the  left  one 
made  scarcely  any  progress.  No  medical  aid  had  ever  been 
sought. 

Examination. — Patient  was  a  small-sized  subject.  He  walked 
with  two  crutches,  using  only  his  right  leg  ;  his  left  leg  hung 
limp  and  loose,  and  was  two  inches  shorter  than  the  other.  The 
muscles  of  the  whole  left  leg,  from  the  gluteal  region  to  the  toes, 
were  very  much  atrophied,  as  were  also  the  muscles  of  the  left 
side  of  the  back  from  the  ninth  dorsal  vertebra  downwards. 

Voluntary  movements  of  left  leg. — Hip-joint :  flexion,  very 
weak ;  extension,  hardly  any ;  abduction,  none ;  adduction, 
slight;   external  rotation,  none;  internal  rotation,  none. 

Knee-joint:  flexion,  very  slight;  extension,  none,  the  quad- 
riceps femoris  for  two  inches  above  the  knee-joint  was  a  mere 
fibrous  band. 

Ankle-joint :  flexion,  a  trace  ;  extension,  a  trace. 

The  abdominal  and  spinal  muscles  were  very  weak.  There 
were  no  reflexes  in  the  left  leg.  Sensation  was  quite  good  in  the 
paralysed  area. 

There  was  considerable  tenderness  over  the  bladder  and  left 
kidney. 

Treatment. 

(1)  Sitting  head  exercise,  PP. 

(2)  Half  lying  left  leg  rolling,  PP.  muscle-kneading,  PP, 
nerve  frictions,  PP. 

(3)  Half  lying  left  leg  flexion  and  extension,  PA. 

(4)  Half  lying  left  foot  rolling,  PP,  flexion  and  extension, 
PA. 


DISEASES  OF  THE  NERVOUS  SYSTEM  439 

(5)  Forwards  lying  back  exercise,  PP. 

(6)  Sitting  trunk  extension  and  flexion,  PA. 

(7)  Sit  lying  left  knee  extension  and  flexion,  PP,  extension, 
PA,  flexion,  PK. 

(8)  Eeach  grasp  toe  standing  double  knee  bending,  PA. 

(9)  Reach  grasp  step  standing  left  knee  flexion  and  extension, 
PA,  left  sciatic  nerve  frictions,  PP. 

(10)  Stretch  stride  standing  bending  forwards,  PA. 

(11)  Half  lying  stomach  exercise,  PP. 

In  the  above  prescription  PA  could  not  always  be  strictly 
adhered  to,  and  in  most  cases  the  movements  had  at  first  to  be 
given  with  assistance,  in  some  even  PP. 

Progress.  —  October  6. — In  sit  lying  position  patient  could 
swing  his  leg  to  and  fro  a  little,  the  maximum  distance  through 
which  the  swinging  took  place  being  two  inches.  He  said  that 
his  back  was  stronger. 

October  8. — Patient's  foot  could  be  actively  flexed  and  ex- 
tended, the  toes  passing  through  about  one  and  a  half  inches  of 
space  (maximum). 

October  2-5. — Patient's  leg  was  stronger  than  before;  the 
atrophy  as  a  whole  was  less.  The  quadriceps  was  larger,  and 
much  thicker  over  the  lower  third  of  the  femur. 

October  31.  —  Patient  could  use  his  quadriceps  to  such  an 
extent  that  he  could  maintain  his  lower  leg,  when  in  sit  lying 
position,  so  that  the  heel  was  about  three  inches  from  the  perpen- 
dicular. 

November  2. — Patient  said  that  his  back  was  still  stronger. 

November  13. — Patient's  calf  muscles  had  developed  propor- 
tionately more  than  his  anterior  tibial  muscles.  He  could  per- 
form foot  extension,  AR,  although  it  was  impossible  to  perform 
flexion  with  even  very  slight  resistance. 

November  17.— Patient  no  longer  needed  support  during 
exercise  (6)  for  the  extension,  but  required  a  little  for  the  flexion. 

November  22.  —  Patient  performed  exercise  (6)  without 
assistance. 

December  20.  —  Treatment  finished  for  the  time  being. 
Patient   stronger. 

Treatment  resumed  on  February  1-5,  1900.  Condition: 
Patient  was  stronger  in  his  back  than  when  he  left  ;  his  leg 
,had    also   improved   slightly.      The   quadriceps   femoris   had   in- 


440      ELEMENTS  OF  KELLGREN'S  MANUAL  TREATMENT 

creased  in  size.  Patient  could  resist  while  extension  at  the 
ankle  was  carried  out ;  could  also  manage  half  lying  leg  flexion, 
PA,  extension,  PA ;  exercise  (6)  could  be  accomphsbed  without 
assistance. 

March  20. — Patient  could  overcome  a  little  resistance  during 
foot  flexion,  AE,  and  could  resist  more  during  foot  extension,  PK. 

April  ]  3  to  16. — No  treatment. 

April  17. — Left  foot  slowly  getting  stronger. 

April  23. — Treatment  suspended  until  May  7. 

May  7. — Treatment  resumed.  Prescription  changed  to  the 
following  : — 

(1)  Sitting  head  exercise,  PP. 

(2)  Lying  left  leg  flexion,  AR,  extension,  PR ;  flexion,  PR, 
extension,  AR. 

(3)  Half  lying  left  foot  rolling,  PP,  flexion  and  extension,  PA. 

(4)  Half  lying  left  leg  rolling,  PP,  flexion  and  extension,  PA. 
(.5)  Half  lying  left  leg  rotation  externally  and  internally,  PA. 

(6)  Forwards  lying  back  exercise,  PP. 

(7)  Sitting  trunk  extension  and  flexion,  PA ;  sit  lying  left 
knee  extension  and  flexion,  PP,  extension,  AR^  flexion,  PR. 

(8)  Ride  sitting  trunk  flexion,  PR,  extension,  AR. 

(9)  Reach  grasp  step  standing  left  knee  flexion  and  extension, 
PA,  left  sciatic  nerve  frictions,  PP. 

(10)  Reach  grasp  toe  standing  double  knee  bending,  PA. 

(11)  Crook  half  lying  double  knee  abduction  and  adduction,  PA. 

(12)  Half  lying  stomach  exercise,  PP. 

If  possible  resistance  was  always  oflered  during  the  PA 
exercises,  in  order  to  increase  their  effect. 

May  23. — Flexors  of  thigh  stronger.  Gluteal  muscles  and 
abductors,  however,  still  very  weak. 

.June  2. — Flexors  of  thigh  still  improving ;  gluteal  muscles 
also  improving. 

June  6. — Anterior  tibial  muscles  improving  considerably. 

July  10. — Not  much  improvement  during  the  last  month, 
excepting  in  the  gluteus  maximus. 

September  2-5. — Patient  finished  treatment. 

Examination. — Patient  could  now  hobble  along  a  little  with- 
out any  support.  The  muscles  of  the  left  leg  as  a  whole  were 
larger  in  bulk. 

Voluntary  movements  of  left  leg. — Hip-joint :    flexion,  good  ; 


DISEASES  OF  THE  NERVOUS   SYSTEM  441 

extension,  fair;  abduction,  weak;  adduction,  good;  external  rota- 
tion, weak  ;    internal  rotation,  very  little. 

Knee-joint :  flexion,  patient  could  flex  it  to  an  anf^le  of  45° 
with  the  couch  when  in  forwards  lying  position,  and  could  offer 
resistance  during  knee  extension,  PR ;  extension,  patient  could 
extend  it  through  an  angle  of  45°  when  in  sit  lying  position,  and 
offer  resistance  during  knee  flexion,  PR. 

Ankle-joint :  flexion,  patient  could  flex  the  foot  to  a  right 
angle  with  lower  leg;  extension,  very  good. 

The  abdominal  and  spinal  muscles  were  stronger.  There  were 
no  reflexes  in  the  left  leg.  There  was  no  tenderness  over  the 
bladder,  but  still  some  over  the  left  kidney. 

Although  this  case  was  not  by  any  means  cured,  it  yet  shows 
what  can  be  effected  even  where  a  condition  of  almost  total 
paralysis  has  existed  for  eleven  years. 

Case  2. 

H.  S.,  female,  aged  '20,  came  under  the  manual  treatment  on 
May  28,  1900. 

History  of  present  illness. — During  November,  1898,  patient 
caught  a  cold  ;  two  days  later,  after  a  feverish  night,  she  found 
that  she  had  lost  the  power  of  movement  in  both  lower  limbs, 
although  sensation  in  them  was  intact.  She  recovered  some 
use  of  them,  however,  and  after  a  week  could  just  manage 
to  walk  along  with  assistance.  She  was  then  taken  to  the  hos- 
pital in  Jonkciping,  where  the  diagnosis  of  poliomyelitis  anterior 
acuta  was  recorded,  and  the  patient  was  given  electricity  daily 
for  eleven  months.  According  to  patient's  account,  a  good  deal 
of  improvement  resulted  in  the  left  leg,  but  very  little  in  the 
right.  During  November,  1899,  she  left  the  hospital,  and  since 
then  her  condition  had  remained  stationary. 

Examination. — May  28,  1900. — Patient  walked  very  slowlj' 
and  with  difliculty ;  her  feet  were  kept  apart,  they  dragged  on 
the  ground,  and  with  each  step  her  body  leant  very  much  over  to 
the  other  side.  Patient  said  that  she  could  not  walk  300  yards 
without  resting,  and  even  walking  100  yards  tired  her  very  much. 
She  complained  of  repeated  attacks  of  cramp  in  the  muscles  of 
the  feet  and  legs  in  general ;  these  often  came  on  every  two  hours 
day  and  night ;  she  had  to  get  out  of  bed  and  walk  about,  the 


44::     ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

pain  being  otherwise  unbearable.  I  could  not  find  any  cause  for 
these  cramps. 

Voluntary  movements. — The  muscles  of  both  limbs  were 
flabby. 

Hip-joint :  Flexion,  right  leg,  not  good  ;  left  leg,  not  good. 
Patient  could  not  lift  either  foot  off  the  ground  unless  she 
leant  very  much  to  the  opposite  side.  Extension,  right,  weak; 
she  could  not  accomplish  the  second  part  of  forwards  lying 
leg  flexion,  PP,  raising,  PA  ;  left,  rather  weak ;  she  could 
just  manage  the  second  part  of  the  exercise  just  mentioned. 
Abduction,  right,  hardly  any ;  in  side  lying  position  she  could 
just  lift  her  foot  off  the  other  leg ;  left,  fair  ;  in  the  position 
just  mentioned  she  could  raise  her  leg  to  form  an  angle  of 
20°  with  the  horizontal.  Adduction,  right,  good  ;  left,  good. 
External  rotation,  right,  weak  ;  left,  weak;  in  half  lying  position 
patient  lay  naturally  with  her  heels  apart  and  her  toes  touching. 
Internal  rotation,  right,  good;    left,  good. 

Knee-joint:  Flexion,  right,  not  good;  left,  quite  good.  Exten- 
sion, right,  not  good  ;  she  could  not  in  sit  lying  position  extend 
her  knee-joint  fully  ;  left,  quite  good. 

Ankle  and  tarsal-joints :  Flexion,  right,  fair;  left,  quite  good. 
Extension,  right,  very  weak ;  even  the  slightest  resistance  pre- 
vented her  executing  this  movement ;  left,  fair.  Eversion,  right, 
none  ;  the  foot  was  kept  inverted ;  left,  fair.  Inversion,  right, 
quite  good  ;  left,  quite  good. 

The  abdominal  and  spinal  muscles  were  also  weak.  Patient 
could  not  perform  sitting  trunk  extension  and  flexion,  PA,  with- 
out a  good  deal  of  help,  and  had  to  be  supported  durmg  stretch 
stride  standing  bending  forwards,  PA,  or  would  have  fallen. 

There  were  no  reflexes  in  either  leg.  No  rectal  or  bladder 
disturbances  were  present. 

Treatment. 

(1)  Eeach  grasp  step  standing  knee  flexion  and  extension, 
PA,  sciatic  nerve  frictions,  PP. 

(2)  Eide  sitting  trunk  flexion,  PE,  extension,  AE. . 

(3)  Eide  sitting  double  arm  abduction,  AE,  adduction,  PE ; 
arm  nerve  frictions,  PP. 

(4)  Stretch  stride  standing  bending  forwards,  PA. 


DISEASES  OF  THE  NERVOUS  SYSTEM  443 

(5)  Forwards  Ij'ing  back  exercise,  PP ;  leg  flexion,  PP, 
raising,  AR. 

(6)  Sitting  trunk  extension  and  flexion,  PA ;  sit  lying  knee 
extension  and  flexion,  PP,  extension,  AR,  flexion,  PE. 

(7)  Standing  vertebral  column  stretching,  AR  at  patient's 
head. 

(8)  Half  lying  leg  rolling,  PP,  flexion,  PA,  extension,  AR. 

(9)  Half  lying  double  foot  rolling,  PP,  flexion,  AR,  extension, 
PR ;  foot  eversion,  AR,  inversion,  PR. 

(10)  Half  lying  stomach  exercise,  PP. 

(11)  Side  lying  leg  lifting,  AR,  pressing  down,  PR  ;    leg  nerve 
frictions,  PP. 

Progress. — May  '29. — No  cramp  during  the  night. 

May  30. — Patient  said  that  she  walked  a  little  better. 

June  1  to  7. — No  cramp. 

June  10. — A  good  deal  of  cramp. 

June  11. — Cramp  disappeared  and  did  not  return  again. 

June  15. — Patient  walked  one  and  a  half  miles,  to  accomplish 
which  took  her  about  two  hours.  Extension  of  both  ankle-joints 
better. 

June  20. — Abduction  at  hip-joints  better. 

July  7. — Extension  of  both  ankle-joints  better,  that  of  the  left 
very  good. 

July  20. — Patient  walked  one  and  a  half  miles,  partly  uphill, 
in  one  and  a  half  hours ;  she  then  walked  the  same  distance 
home  in  one  hour. 

August  1.5. — Abduction  of  left  leg  very  good.  Eversion  of  left 
foot  very  good,  that  of  right  foot  somewhat  better. 

August  20. — Patient  walked  one  and  a  half  miles,  over  the 
same  course  as  on  July  20,  in  one  hour ;  she  then  walked  home 
in  fifty  minutes. 

September  15.  —  Treatment  suspended  for  fourteen  days ; 
patient  felt  so  strong  that  she  took  a  situation   as  nurse-maid. 

October  1. — Patient  returned  to  treatment ;  from  this  day 
onwards  she  daily  walked  to  and  from  her  place  of  residence  to 
my  house  in  order  to  get  treatment,  distance  nearly  one  mile  ;  at 
present  this  took  half  an  hour  each  way. 

October  22. — Patient  only  took  twenty  minutes  to  walk  to  my 
house. 

November  5. — Patient  walked  with  a  slight  waddling  gait ; 


444    ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

the  eversion  of  the  right  foot  was  not  restored  yet,  hut  the  move- 
inents  of  the  left  leg  were  ahiiost  noriiuil.  There  was  a  sHght 
patellar  reflex  on  the  left  side. 

December  20.— Treatment  finished. 

Examination. — Patient  walked  very  much  better ;  she  came 
from  her  house  to  mine  in  fifteen  minutes.  She  only  leant  her 
body  a  little  over  to  one  side  while  walking.  There  was  still  a 
tendency  for  the  feet  to  be  dragged  as  she  walked. 

Voluntary  movements  of  right  leg. — The  muscles  of  the  right 
leg  were  still  flabby,  but  the  left  leg  appeared  to  be  quite  strong, 
the  only  weakness  being  in  abduction  of  the  hip-joint  and  ever- 
sion of  the  foot. 

Hip-joint:  Flexion,  normal;  extension,  normal;  abduction, 
good ;  patient  could  abduct  her  leg  to  an  angle  of  "20°  in  side 
lying  position;  adduction,  normal;  rotation,  external,  not  good; 
internal,  good. 

Knee-joint:    Flexion,  normal ;  extension,  normal. 

Ankle  and  tarsal-joints  :  Flexion,  good  ;  extension,  fair ;  ever- 
sion, fair ;  inversion,  normal. 

The  abdominal  and  spinal  muscles  were  much  stronger. 
Patient  could  perform  sitting  trunk  extension  and  flexion,  PA, 
quite  well  without  help. 

There  was  a  patellar  reflex  on  the  left  side,  but  none  on  the 
right. 

Facial  Paralysis  of  Peripheral  Origin. 

G.  A.,  male,  age  7,  came  under  the  manual  treatment  on 
August  12,  1898. 

Historij  of  present  ilbtess. — Patient  had  been  running  about 
very  much  on  August  10 ;  while  in  a  great  state  of  perspiration 
he  took  a  bath  in  the  lake  close  by.  During  the  morning  of 
August  11  his  mother  noticed  that  "his  face  was  crooked." 
On  August  12  it  was  still  crooked,  and  he  could  not  move  the 
right  side. 

Examination. — August  12. — There  was  complete  paralysis  of 
the  right  side  of  the  face,  which  was  smooth ;  there  was  lachry- 
mation  of  the  right  eye,  which  remained  open.  There  was  no 
voluntary  movement  in  the  right  half  of  the  face,  neither  in  the 
frontal  part  of  the  occipito-frontalis  muscle,  nor  cheek,  nor  in  the 
lower  part  of  the  face  or  lips.     The  mouth,  when  patient  smiled, 


DISEASES  OF  THE   NERVOUS  SYSTEM  445 

was  drawn  to  the  left  side.  The  food  collected  in  the  right  cheek 
during  eating.  Speech  was  not  impaired.  Taste  and  hearing 
were  normal. 

Treatment. — Frictions  on  the  facial  nerve  and  its  branches. 
Patient  was  urged  to  try  and  move  his  face  voluntarily.  Some 
general  movements  were  added. 

Progress. — The  first  sign  of  movement  came  on  August  20  ; 
patient  could  smile  a  little  on  his  right  side.  The  occipito- 
frontalis  could  be  wrinkled  by  August  22.  The  face  was  normal 
by  September  10,  with  the  e.Kception  that  the  right  eye  could  not 
close  properly.  Treatment  was  suspended  until  October  6,  when 
it  was  resumed  by  Dr.  A.  Moller,  who  cured  the  remaining  eye 
weakness  in  three  weeks. 

October,  1902. — The  face  was  quite  normal. 

Post-Diphtheritic    Paralysis. 

(From  notes  taken  by  Dr.  A.  Moller  and  myself.) 

M.  G.,  female,  aged  13,  came  under  the  manual  treatment  on 
October  16,  1899. 

History  of  present  illness. — When  8  months  of  age  patient  had 
scarlet  fever  and  diphtheria,  with  convulsions.  Soon  after  that 
the  paralytic  symptoms  were  first  noticed.  Many  medical  men 
were  consulted,  who  all  said  that  the  condition  was  one  of  post- 
diphtheritic paralysis ;  but  none  of  their  prescriptions  seemed  to 
have  any  effect.  The  condition  remained  almost  unchanged 
during  the  next  eleven  years. 

Examination. — The  appearance  was  one  of  continually  half 
laughing,  and  the  expression  was  somewhat  vacant.  The  mouth 
could  only  be  opened  about  half  way.  The  speech  was  nasal, 
although  the  palate  was  fairly  moveable.  There  was  great 
difficulty  in  moving  the  tongue,  as  the  frenum  Imguse  was 
much  contracted.  The  tongue  could  only  be  protruded  as  far 
as  the  lower  margui  of  the  lower  front  teeth.  Patient  could 
not  hft  the  tongue  voluntarily.  Salivation  was  very  great  in 
amount  and  continually  running  out  of  the  side  of  the  mouth. 
Patient  could  not  pronounce  1,  t,  d,  and  n  at  all ;  her  speech  was 
on  the  whole  very  thick  and  at  times  almost  unintelligible. 
Swallowing  was  impaired.     There  was   also  partial   paralysis   of 


446     ELEMENTS    OF   KELLGREN'S    MANUAL    TREATMENT 

the  right  upper  extremity  ;  the  supinators  and  extensors  of  the 
forearm  were  very  weak,  and  patient  could  not  oppose  her  thumb. 
Frictions  on  the  brachial  plexus  in  the  axilla,  ulnar  nerve,  &c., 
caused  sensation  only  at  the  point  of  application,  and  even  that 
was  diminished. 


Treatment. 

The  special  exercises  were  : — ■ 

(1)  Sitting  head  exercise  and  throat  exercise  ;  and  trigeminal, 
facial,  lingual,  and  hypoglossal  nerve  frictions,  PP. 

Patient  had  to  practise  daily  protruding  the  tongue,  saying 
the  letters  she  had  special  difficulty  in  pronouncing,  trying  to 
breathe  without  letting  the  air  escape  by  the  nose,  &c.,  in 
short,  trying  to  do  what  paralysis  had  hitherto  prevented. 

(2)  Reach  grasp  standing  head  flexion,  PE,  extension,  AR, 
cervical  nerve  frictions,  PP. 

(3)  Sitting  right  arm  exercise,  including  supination,  AE, 
pronation,  PR;  hand  extension,  AE,  flexion,  PE ;  thumb  adduc- 
tion, AE,  abduction,  PE,  kc. 

(4)  Stretch  grasp  standing  drawing  forwards,  PP,  kidney 
frictions,  PP. 

Some  general  movements  for  the  constitution  were  also  pre- 
scribed. 

Progress. — November  15. — Less  salivation  ;  swallowing  easier. 
The  tip  of  the  tongue  could  be  placed  against  the  upper  front 
teeth.  L,  t,  d  and  n  could  be  pronounced  fairly  well ;  speech  was 
much  clearer.  Supination  better ;  patient  able  to  open  doors 
needing  supination  to  perform  the  turning  of  the  handle ;  she 
could  not  do  so  before  on  the  same  door.  Extension  of  the 
lingers  better.  The  thumb  could  be  opposed  to  the  tip  of  the 
little  finger. 

December  8. — Improvement  mantained.  Patient  compelled  to 
discontinue  the  treatment  for  the  time  being. 

February  1-5,  1900. — Treatment  resumed.  Speech  had  slightly 
improved  during  absence,  and  the  extensors  of  the  forearm 
were  stronger. 

March  15. — -Treatment  again  interrupted.  The  muscles  of  the 
forearm  had  continued  to  progress  during  the  last  month. 

April  3. — Treatment    resumed.      Frictions    on    the    brachia 


DISEASES  OF  THE  NERVOUS  SYSTEM  447 

plexus,  even  when  not  given  strongly,  caused  sensation  in  the 
finger  tips. 

April  14. — Treatment  finished.  Patient's  general  condition 
better.  Saliva  hardly  ever  ran  from  the  mouth  any  more ; 
speech  was  fairly  clear  and  intelligible,  and  t  and  d  could  be 
pronounced  fairly  well.  Patient  had  begun  to  learn  to  write 
with  her  right  hand ;  both  supination  and  extension  of  the 
forearm  were  very  good,  and  household  work  could  be  done  with 
both  hands. 

The  total  duration  of  treatment  was  about  three  months  and 
one  week.  I  firmly  believe  that  further  improvement,  little  if  at 
all  short  of  complete  cure,  would  have  resulted  had  patient  been 
able  to  receive  the  treatment  uninterruptedly  from  the  beginning 
and  to  continue  it  for  another  few  months.  Unfortunately  this 
was  impossible. 

Neuralgia  and  Neuritis. 

I  have  in  several  instances  produced  immediate  and  per- 
manent relief  in  quite  fresh  cases  of  supraorbital,  ulnar,  and 
occipital  nerve  neuralgia,  which  came  to  me  within  twenty-four 
hours  of  the  first  manifestations  of  the  symptoms.  The  treat- 
ment was,  locally,  vibrations  or  frictions  over  the  affected  nerves. 


Case  1. — -Supraorbital  Neuralgia. 
(From  notes  taken  by  Dr.  A.  Mciller  and  myself.) 

Mr.  S.,  engineer,  aged  22,  came  under  the  manual  treatment 
on  February  24,  1900. 

History  of  present  illness. — On  February  14  patient  caught  a 
cold,  and  severe  constant  pain  set  in  in  the  right  side  of  the  fore- 
head; this  became  worse  and  worse.  On  February .17  the  other 
side  of  the  forehead  was  similarly  affected.  On  February  19 
patient  consulted  a  medical  man  who  prescribed  antipyrin  and 
rest  at  home  for  a  week.  On  February  24,  as  patient's  condition 
had  been  getting  still  worse.  Dr.  A.  Moller  and  I  were  called  in. 

Patient  complained  of  severe  pain  in  the  forehead,  which  was 
intensified  by  a  light  friction  on  the  supraorbital  nerves.  There 
was  more  pain  in  the  nerve  of.  the    left  side.     Treatment  was 


44S     ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

at  once  administered,  consisting  of  vibrations  over  the  nerves 
specified  and  a  few  general  movements.  Patient  felt  much 
better  after  it,  and  there  was  much  less  pain. 

On  February  25  patient  vs^alked  to  my  house  (distance  one 
mile).  He  stated  that  one  bad  relapse  of  the  pain  had  occurred 
during  the  night,  lasting  twenty  minutes ;  otherwise  he  had  felt 
better.  There  was  now  no  pain  in  the  right  supraorbital  nerve, 
although  in  the  left  supraorbital  nerve  some  remained  ;  the  latter, 
however,  disappeared  entirely  during"  the  treatment  (which  was 
in  all  essentials  the  same  as  before). 

February  26. — Very  slight  pain  in  the  nerve  of  the  left  side. 
Treatment  for  the  last  time. 

July  20,  1900. — No  relapse  of  any  kind  whatever  had  taken 
place. 

Case  2. — Sciatica. 

H.  L.,  male,  occupation  metal  polisher  in  a  factory,  aged  30, 
came  under  the  manual  treatment  on  August  19,  1902. 

History  of  present  illness. — About  nine  weeks  ago  patient 
began  to  feel  a  continued  boring  pain  in  his  right  thigh  and 
gluteal  region;  although  at  first  slight  this  pain  increased  in 
intensity,  and  after  about  a  fortnight  was  so  bad  that  he  could 
not  sit  without  great  inconvenience.  He  was  by  this  time  unable 
to  bend  forwards  so  as  to  pick  up  anything  off  the  ground.  His 
condition  became  worse,  and  on  July  2-5  he  was  obliged  to  cease 
work  at  the  factory.  On  August  15  he  consulted  Dr.  Eric 
Hellberg,  of  Jonkoping,  who  recommended  him  for  the  manual 
treatment.     No  internal  remedies  were  prescribed. 

Examination. — Patient  walked  with  a  slight  limp.  He  com- 
plained of  continued  severe  boring  pain  in  the  gluteal  region  and 
back  of  the  thigh,  occasionally  extending  down  the  back  of  the 
lower  leg.  He  could  sleep  fairly  well  in  spite  of  the  pain. 
Occasionally  there  were  acute  exacerbations  of  the  pain  even 
when  standing  still,  and  the  pain  was  aggravated  by  sitting  down. 
Any  movement  that  stretched  the  painful  parts  greatly  increased 
the  pain ;  patient  could  for  example  in  stretch  stride  standing 
position  hardly  bend  the  trunk  forwards.  There  was  great 
atrophy  of  the  gluteal  muscles  and  of  the  thigh  muscles  pos- 
teriorly, also  to  a  less  extent  of  the  muscles  of  the  calf.     There 


DISEASES  OF   THE  NERVOUS  SYSTEM  449 

was  great  tenderness  to  pressure  over  the  course  of  the  superior 
ghiteal,  inferior  gluteal,  great  sciatic  and  internal  popliteal  nerves, 
and  to  a  less  extent  over  the  posterior  tibial,  internal  plantar,  and 
external  popliteal  nerves. 

Trcatinent. 

A  great  deal  of  attention  has  lately  been  directed  to  the 
muscular  atrophy  so  constantly  found  in  cases  of  sciatica  even 
if  of  comparatively  quite  recent  standing,  and  massage  of  the 
atrophic  parts  has  been  strongly  recommended  by  many  authors. 
This  procedure,  no  doubt,  in  the  course  of  time  cures  some  cases, 
but  I  consider  that  this  is  due  chiefly  to  the  manipulation  reach- 
ing the  affected  nerve,  and  not  to  the  stimulation  of  the  muscles. 
It  must  be  borne  in  mind  that  in  bad  cases  of  sciatica  a  primary 
neuritis  has  to  be  dealt  with,  and  that  the  atrophy  of  the  muscles 
is  secondary  to  it. 

The  manual  treatment  is  directed  towards  the  real  seat  of  the 
disease,  i.e.,  the  great  sciatic  nerve  itself.  Local  treatment  is 
administered,  consisting  of  vibrations,  and  as  soon  as  possible 
frictions,  on  the  nerve  itself,  and  movements  of  the  leg  to  pro- 
mote the  circulation  of  the  blood  and  lymph.  Movements  are 
also  prescribed  that  alternately  stretch  and  relax  the  affected 
nerve.  General  constitutional  exercises  are  added  in  order  to 
raise  the  vital  activity  of  the  body  as  a  whole. 

The  following  was  the  prescription  in  the  case  which  is  being 
described  : — 

(1)  Reach  grasp  step  standing  right  knee  flexion  and  extension, 
PA,  given  with  vibrations  on  the  gluteal  and  great  sciatic 
nerves,  PP. 

(2)  Forwards  l3'ing  back  exercise,  PP ;  right  leg  flexion,  PP, 
raising,  AE. 

(3)  Stretch  stride  standing  bending  forwards,  PA. 

(4)  Stretch  half  lying  running  nerve  frictions,  PP,  kidney 
frictions,  PP. 

(.5)  Ride  sitting  trunk  flexion,  PR,  extension,  AR. 

(6)  Lying  right  leg  flexion,  PR,  extension,  AR. 

(7)  Half  lying  right  leg  rolling,  PP,  flexion,  PA,  extension, 
AR. 

(8)  Stride  sit  kneeling  raising,  AR. 
29 


450     ELEMENTS  OF  KELLGREN'S  MANUAL   TREATMENT 

(9)  Half  l3'iiig  stomach  exercise,  PP,  followed  by  vibrations 
ou  the  affected  nerves,  PP. 

In  exercises  (1)  and  (9),  frictions  were  substituted  for  vibrations 
at  the  earliest  opportunity,  as  soon  as  the  pain  had  sufficiently 
diminished. 

Progress. — September  80. — Treatment  finished.  Owing  to  mj^ 
temporary  absence  I  did  not  see  patient  until  October  5,  1902. 

Examination. — Patient  much  better.  No  pain  in  the  gluteal 
or  great  sciatic  nerve  or  its  ramifications  on  standing  still  or  on 
sitting  down.  After  walking  a  good  deal  a  little  pain  sometimes 
felt.  Patient  able  to  execute  stretch  stride  standing  bending  for- 
wards, PA,  until  his  finger-tips  touched  the  ground  ;  a  little  pain 
caused  meanwhile.  Atrophy  of  muscles  considerably  less.  No 
tenderness  to  pressure  over  the  superior  and  inferior  gluteal 
nerves ;  some  still  remaining  over  the  great  sciatic  nerve  in  its 
upper  part. 

Patient  returned  to  his  work  at  the  factory  on  September  27, 
1902.     Further  history  unknown. 


Case  3. — Sciatica. 
(Treated  by  Dr.  A.  Moller  and  myself.) 

K.  K.,  male,  aged  40,  whose  occupation  was  that  of  attending 
to  a  screw-making  machine,  which  necessitated  his  standing  all 
day,  came  under  the  manual  treatment  on  August  29,  1898. 

History  of  present  illness. — About  September,  1897,  patient 
began  to  suffer  from  pain  in  his  right  thigh  posteriorly  in  the 
region  of  the  great  sciatic  nerve ;  the  pain  became  steadily  worse, 
and  about  Christmas  began  to  disturb  his  sleep.  It  now  also 
appeared  in  the  back  of  the  lower  leg,  became  continuous,  and 
was  of  a  gnawing  character.  By  the  end  of  March,  1898,  it  was 
so  bad  that  he  was  obliged  to  stop  work.  He  tried  a  two 
month's  treatment  of  Ling's  medical  gymnastics,  but  this  had 
no  effect ;  he  then  underwent  a  bath  and  massage  cure  for  five 
weeks,  which  made  him  somewhat  better ;  on  coming  home  he 
tried  to  work  again.  The  sciatica,  however,  at  once  got  worse, 
and  in  a  fortnight  was  as  bad  as  before ;  patient  was  obliged  once 
more  to  cease  work. 

Examination. — Patient  looked  pale  and  thin.    He  said  that  he 


DISEASES  OF  THE  NERVOUS  SYSTEM  451 

slept  veiy  little  indeed,  the  pain  in  his  leg  being  so  bad.  He 
walked  with  a  slight  limp,  and  complained  of  constant  severe 
gnawing  pain  in  the  back  of  the  right  thigh  and  lower  leg  in  the 
area  of  the  great  sciatic,  internal  popliteal,  and  posterior  tibial 
nerves.  This  was  greatly  aggravated  by  movement,  even  by  flexion 
forwards  of  the  head,  which  caused  the  pain  to  be  felt  also  in 
the  region  of  the  internal  plantar  nerve.  From  stretch  stride 
standing  position,  flexion  forward  of  the  trunk  could  not  be 
executed  through  more  than  an  angle  of  about  10°,  on  account  of 
the  great  pain  induced.  There  was  great  tenderness  to  pressure 
along  the  whole  of  the  right  great  sciatic  nerve  and  its  prolonga- 
tion down  to  the  internal  plantar  nerve,  the  tenderness  in  the 
latter,  however,  not  being  so  marked  as  in  the  former.  There 
was  considerable  atrophy  of  the  whole  of  the  muscles  of  the 
right  thigh  and  lower  leg,  the  difference  between  the  maximum 
circumferences  of  these  parts  being  about  an  inch  less  than 
the  corresponding  ones  on  the  left  side. 

The  treatment  was  on  the  lines  already  indicated. 

Progress.  —  After  the  first  week  improvement  set  in  and 
patient  could  sleep  better.  From  the  eighth  day  onwards  the 
pain  became  less  severe,  and  patient  could  perform  the  move- 
ments that  stretched  his  affected  nerves  with  increasing  facilitj'. 
By  the  end  of  September  he  could  execute  stretch  stride  standing 
bending  forwards,  PA,  so  far  that  at  the  conclusion  of  the  flexion 
his  finger-tips  touched  the  ground.  By  the  middle  of  October 
the  pain  had  quite  disappeared,  and  there  was  no  appreciable 
difference  in  the  circumference  of  the  thigh  and  lower  leg  of 
the  right  and  left  legs  respectively.  Patient  continued  treat- 
ment until  October  30,  when  he  was  quite  cured. 

I  saw  patient  again  during  August,  1902.  He  said  that  after 
standing  very  much  his  right  leg  felt  more  tired  than  his  left ; 
otherwise  there  was  nothing  abnormal  to  be  recorded,  and  he  had 
never  had  the  slightest  return  of  the  pain. 

Mental    Overwork. 

Miss  H.,  schoolmistress,  aged  32,  of  a  nervous  temperament, 
came  under  the  manual  treatment  on  April  24,  1900. 

History  of  i^resent  illness. — Patient  had  for  some  months  past 
had  a  great  deal  of  brain  work  to  do,  and  for  three  weeks  past  she 


453      ELEMENTS  OF  KELLGREN'S    MANUAL    TREATMENT 

had  felt  day  by  day  progressively  weaker.  On  April  21  during 
the  morning  and  afternoon  she  had  about  ten  distinct  attacks  of 
a  peculiar  nature  ;  she  suddenly  had  amaurosis  and  felt  as  if  she 
were  being  lifted  up  and  thrown  down  on  the  ground.  A  few 
seconds  later  vision  returned,  and  she  was  surprised  to  find  that 
she  was  still  standing  up.  Great  heat  and  heaviness  in  the  head 
accompanied  these  attacks,  and  was  present  to  a  minor  degree 
during  the  intervals ;  between  the  attacks  she  had  considerable 
difficulty  in  walking,  as  her  legs  felt  shak}'.  Palpitation  came  on 
every  now  and  then.  On  April  22,  having  slept  very  badly, 
patient  woke  up  feeling  very  weak,  and  with  a  commencing 
sensation  of  sickness.  As  it  was  Sunday,  she  did  not  need  to 
go  to  school,  and  became  a  little  better  during  the  day  as  she  was 
able  to  keep  quiet.  On  April  23  she  went  to  school  again,  and 
just  managed  to  get  through  her  work.  The  sensation  of  sick- 
ness was  worse.  Her  appetite  remained  good,  however,  during 
the  whole  time,  and  she  usually  felt  better  after  eating.  On 
April  24  she  again  went  to  school,  but  felt  so  bad  that  she  had 
to  lie  down  on  a  sofa  in  the  teachers'  room  soon  after  arriving, 
and  later  on  was  compelled  to  go  home. 

Examination. — April  24. — Patient  complained  of  weakness, 
headache,  feeling  of  heat  ni  the  head,  and  unpleasant  sensations 
in  the  epigastrium.  She  stated  that  she  was  totally  unable  to 
read,  and  the  very  idea  of  doing  so  was  almost  unendurable. 
Patient  was  thinner  than  when  I  saw  her  fourteen  days  previ- 
ously, and  looked  somewhat  anajmic.  The  head  was  very  hot  to 
the  touch,  specially  in  the  occipital  region.  There  had  been 
palpitation  at  intervals  during  the  day. 

Treatment. 

(1)  Sitting  head  exercise,  PP. 

(2)  Forwards  lying  back  exercise,  PP. 

(3)  Ride  sittmg  trunk  flexion,  PR,  extension,  AR. 

(4)  Ride  sitting  double  arm  abduction,  AR,  adduction,  PR ; 
arm  nerve  frictions,  PP. 

(5)  Ride  sitting  alternate  rotation,  AR ;  ringing,  PP,  added 
later  on. 

(6)  Stretch  stride  standing  bending  forwards,  PA. 

(7)  Half  lying  leg  rolling,  PP,  flexion,  PA,  extension,  AR. 


DISEASES  OF   THE  NERVOUS  SYSTEM  453 

(8)  Sitting  trunk  extension  and  liexion,  PA. 

(9)  Half  lying  stomach  exercise,  PP. 

Progress. — After  the  first  treatment  patient  felt  better ;  she 
slept  very  well  during  the  ensuing  night. 

April  25. — Patient  still  quite  unable  to  attempt  reading.  After 
treatment  she  was  rather  giddy  all  the  evening  (time  of  treat- 
ment was  5  p.m.)  until  11  p.m.,  when  she  retired  to  bed  and 
slept  well. 

April  30.—  Steady  improvement  daily  since  April  26.  Patient 
still  felt  very  weak,  but  her  head  was  a  good  deal  better. 

May  1. — Patient  had  slept  badly.  Condition  otherwise  about 
the  same. 

May  2. — Patient  felt  ver}'  well ;  the  school  class  came  to  her 
house  and  received  an  hour's  instruction. 

May  3. — Patient  very  well.  No  class  to  teach  during  the  day, 
as  the  work  was  done  by  others. 

May  4. ^Patient  drove  to  school  and  gave  an  hour's  instruc- 
tion.    She  walked  home  (distance  fifteen  minutes'  walk). 

May  5. — Patient  walked  half  way  to  school,  and  drove  the 
other  half.  She  gave  one  hour's  instruction  and  then  walked 
home. 

May  6  (Sunday). — Treatment.  Patient  almost  well.  Palpita- 
tion during  the  evening. 

Ma}'  7. — Patient  walked  to  school  and  back,  and  taught  for 
four  hours.  Her  head  remained  quite  well,  biTt  was  easily 
fatigued. 

May  8. — Patient  rather  tired  after  the  efforts  of  the  previous 
day.  Head  as  on  May  7.  Occipital  region  much  less  hot  than 
on  April  24. 

May  9. — Condition  about  the  same.  Four  hours  teaching  at 
school. 

May  10. — Patient  slept  excellently  during  the  night ;  walked 
to  school  quite  easily ;  felt  very  well  and  did  her  four  hours'  work 
with  ease.  She  was  tired  in  her  head  during  the  afternoon  ;  this 
disappeared  after  treatment. 

May  11  and  12. — Treatment  both  days.  Patient  was  able  to 
teach  as  usual  on  both  days.  On  12th  (Saturday)  she  felt  tired, 
but  revived  during  the  afternoon. 

May  13. — No  treatment.     Very  tired  all  day. 

May  14. — Diarrhcea  early  in  the  morning  and  once  again  at 


454  ELEMKXTS  OF    KELLGREN'S    MAM  UAL    TREATMENT 

night ;  after  it  patient  felt  better  than  on  any  occasion  since  her 
ilhiess. 

May  16,  17,  18,  21,  23. — Patient  very  well  indeed  during  all 
this  week.     Treatment  once  daily. 

May  25,  28.— Treatment. 

May  29. — School  finished  for  the  term. 

June  1,  2. — Treatment.     Patient  very  well  indeed. 

June  5,  6,  8,  9,  11,  12,  14,  1.5.— Treatment.  Patient  very  well 
indeed. 

June  15. — Treatment  finished.     Patient  normal. 


Sequelae  of  Influenza. 

Case  1. 
(From  notes  taken  by  Dr.  A.  Moller  and  myself). 

Miss  T.,  aged  23,  schoolmistress,  came  under  the  manual 
treatment  on  October  13,  1899. 

History  of  present  illness. — Patient  had  influenza  in  February, 
1899,  and  ever  since  then,  when  teaching,  had  had  violent  neu- 
ralgic attacks  either  in  the  supraorbital  or  lateral  frontal  regions, 
with  headache  all  over  the  head,  and  much  pain  in  her  eyes. 
These  attacks  generally  came  on  after  she  had  been  working 
about  half  an  hour,  and  lasted  sometimes  all  day,  i.e.,  from 
9  a.m.  to  5  p.m.,  at  which  hour  school  finished ;  sometimes  they 
lasted  all  the  evening  as  well.  Patient's  general  condition  had 
become  weakened  and  nervous. 

Examination.  —  The  supraorbital  and  great  occipital  nerves 
were  very  tender  to  the  touch.  The  head  felt  hot.  Patient  was 
very  sensitive  over  the  whole  body  wherever  I  touched  her. 

Treatment. — The  special  movements  prescribed  were : — 

(1)  Sitting  head  exercise,  with  vibrations  over  the  affected 
nerves  and  the  eyeballs,  PP. 

(2)  Keach  grasp  standing  head  flexion,  PE,  extension,  AR, 
cervical  nerve  frictions,  PP. 

(3)  Forwards  lying  back  exercise,  PP. 

(4)  Stretch  grasp  standing  drawing  forwards,  PP,  kidney 
frictions,  PP. 

Besides  these,  some  other  general  movements  were  added. 
Patient  could  not  leave  off  her  teaching,  and   continued   it 
daily  as  usual. 


DISEASES  OF  THE  NERVOUS  SYSTEM  455 

Prof/ress. — October  '25. — Neuralgia  less  intense. 

October  26. — Only  one  neuralgic  attack,  lasting  half  an  hour. 

November  2. — No  neuralgic  attack  at  all  during  the  previous 
day.     Headache  better. 

November  9.  — Hardly  any  headache  during  the  last  week. 

November  11. — Patient  considered  herself  practically  cured. 
No  headache. 

August,  1900. — After  very  hard  work  a  slight  pain  was 
occasionally  felt  in  the  supraorbital  region ;  otherwise  patient 
had  kept  quite  well  since  the  treatment  was  finished. 


Case  "2. 
(From  Notes  taken  by  Dr.  A.  Moller  and  myself.) 

J.,  aged  39,  coachman,  came  under  the  manual  treatment  on 
November  19,  1899. 

History  of  present  illness.  —  Patient  drank  a  good  deal. 
During  March,  1899,  he  had  an  attack  of  influenza,  and  got  up 
too  soon.  Since  then  he  had  continually  suffered  pains  in  his 
head  and  body  generally;  these  pains  were  not  always  in  the 
same  place,  but  moved  about.  He  sometimes  had  attacks  of 
giddiness  and  buzzing  sounds  in  his  head.  There  was  general 
nervousness  and  weakness.  Patient  was  shaky  on  his  legs.  His 
appetite  had  remained  fairly  good,  but  both  taste  and  smell  had 
become  deficient.  His  condition  had  existed  almost  unchanged 
since  getting  up  after  influenza,  in  spite  of  various  remedies  pre- 
scribed. Nothing  particular  could  be  elicited  on  examination, 
except  that  the  back  of  the  head  was  hot  to  the  touch. 

Tj-eafincnt. 

(1)  Sitting  head  exercise,  including  ear  vibration,  PP. 

(2)  Eeach  grasp  standing  head  flexion,  PB,  extension,  AK, 
cervical  nerve  frictions,  PP. 

(3)  Heave  grasp  standing  chest  clapping,  PP,  side  shaking, 
PP. 

(4)  Forwards  lying  back  exercise,  PP. 

(5)  Half  lying  double  foot  rolling,  PP,  flexion  and  extension, 
AE. 


456     ELEMENTS  OF   KELLGREN'S   MANUAL    TREATMENT 

(6)  Stretch  grasp  standing  drawing  forwards,  PP,  kidney 
frictions,  PP. 

(7)  Stretch  stride  standing  bending  forwards,  PA. 

(8)  Half  lying  double  leg  rolling,  PP,  flexion,  PA,  extension, 
AE. 

(9)  Half  lying  stomach  exercise,  PP,  spleen  frictions,  PP. 
Progress. — November  20. — Patient  easier  in  his  head. 
November  28. — Patient  still  easier  in  his  head. 

December  2. — No  pains  in  body ;  some  buzzing  sounds  in 
head  ;  patient  otherwise  felt  quite  well. 

December  16. — Smell  and  taste  restored  ;  patient  very  nearly 
normal.     Treatment  interrupted  until  January  4,  1900. 

January  4,  1900. — Patient  returned  to  treatment,  as  the  pains 
in  his  body  had  recommenced. 

February  7. — Occasionally  feeling  of  giddiness  (perhaps  due 
to  the  alcohol  taken).  Patient  otherwise  normal.  Treatment 
finished. 

June,  1902. — Patient  keeping  quite  well. 

Chronic  Headache.' 

Mrs.  C,  aged  88,  came  under  treatment  on  November  1,  1900. 

History  of  present  illness. — Ever  since  the  age  of  15  she  had 
suffered  from  continual  headache,  with  only  occasionally  a  few 
days  intermission.  The  usual  course  of  the  headache  was  as 
follows  :  On  waking  up  there  was  not  much.  After  getting  up  a 
slight  amelioration  sometimes  occurred ;  then  usually  an  acute 
attack  came  on ;  in  about  two  minutes  violent  pains  were  felt  in 
the  back  of  the  head ;  these  spread  up  to  the  vault  of  the  skull 
and  settled  there  as  well.  Then  the  temples  and  eyes  became 
affected.  Usually  patient  was  so  bad  that  she  could  not  even 
read.  During  the  afternoon  the  pains  subsided  somewhat ;  but 
during  the  evening  they  often  became  worse  again. 

Patient  continually  suffered  from  cold  legs  and  feet,  and  slept 
badly.  Movement  and  exertion  usually  aggravated  the  condition; 
mental  worry  nearly  always  did  so.  At  meal  times  there  was, 
if  anything,  a  slight  improvement. 

'  A  great  deal  has  of  late  been  made  of  the  supposed  fact  that  chronic  neuralgic 
headache  can  be  caused  by  myositis  of  the  neck  muscles  ;  massage  of  these  muscles 
has  been  recommended,  and  good  results  appear  to  be  obtained  thereby.  To  my 
mind  the  muscular  affection  is  secondary  to  a  primary  nerve  irritation,  and  much 
quicker  results  can  be  obtained  by  nerve  vibrations. 


DISEASES  OF  THE  NERI'OUS  SYSTEM  457 

Treafment. 

(1)  Sitting  head  exercise,  PP. 

(2)  Eeach  grasp  standing  head  flexion,  PR,  extension,  AR, 
frictions  on  the  second  cervical  nerves,  PP. 

(3)  Ride  sitting  double  arm  abduction,  AR,  adduction,  PR, 
arm  nerve  frictions,  PP. 

(4)  Half  lying  double  foot  rolling,  PP,  flexion  and  extension, 
AR. 

(5)  Forwards  l3'ing  back  exercise,  PP. 

(6)  Stretch  half  lying  double  arm  rolling,  PP,  bending  and 
stretching,  AR. 

(7)  Sit  lying  knee  extension  and  flexion,  PP,  extension,  AR, 
flexion,  PR. 

(8)  Pleave  grasp  standing  chest  clapping,  PP,  side  shaking, 
PP. 

(9)  Half  lying  leg  rolling,  PP,  flexion,  PP,  extension,  AR. 
(10)  Half  lying  stomach  exercise,  PP. 

Progress. — November  8. — Headache  had  been  gradually  dimin- 
ishing during  the  week.     None  at  all  during  this  day. 

November  14.— No  return  of  the  headache  until  this  evening. 

November  15. — No  headache. 

November  16. — A  little  headache,  as  patient  had  worked  very 
hard  during  the  previous  evening. 

November  17. — No  headache. 

November  28. — No  headache  since  November  17.  Feet  and 
legs  now  always  warm.  Patient  said  that  she  felt  very  well. 
Treatment  finished. 

July,  1902. — No  return  of  the  headache. 

Epileptic  Seizure  while  Bathing. 

A.,  factory  worker,  aged  3-5,  came  under  the  manual  treat- 
ment on  July  19,  1900. 

History  of  present  illness. — Patient  had  sufl'ered  from  chronic 
rheumatism  for  a  year.  Two  months  ago  he  was  operated  on  for 
htemorrhoids,  and  since  then  had  not  felt  very  well.  On  July  19, 
1900,  he  went  to  bathe.  Suddenly  he  felt  a  kind  of  cramp  in 
his  feet,  and  he  remembered  feeling  it  passing  up  his  legs  and 
abdomen.     He  felt  he  was  falling  and  screamed  for  help.     After 


458     ELEMENTS  OF   KELLGREN'S    MANUAL    TREATMENT 

that  he  remeinhered  nothing  moru.  The  friends  of  the  patient 
told  me  that  they  saw  him  fail  back  into  the  water  and  dis- 
appear entirely  from  view,  and  about  five  minutes  elapsed  before 
they  were  able  to  get  him  out.  When  at  last  they  did  he  was 
in  a  state  of  opisthotonic  rigidity.  They  tried  to  perform  arti- 
ficial respiration.  Dr.  Harry  Kellgren  and  I  were  sent  for  and 
arrived  at  .5.45  p.m.,  fifteen  minutes  after  the  accident. 

Examination.  —  Patient  profoundly  unconscious,  markedly 
cyanotic,  eyes  closed.  Breathing  laboured  and  stertorous ;  con- 
tinued spasmodic  movements  of  the  head,  which  was  turned  to 
the  left  side.  Every  now  and  then  the  eyes  opened  and  I  saw 
that  both  pupils  were  widely  dilated.  Occasionally  spasmodic 
movements  of  the  lower  limbs  took  place,  and  at  fairly  regular 
intervals  of  a  few  seconds  patient  screamed  aloud,  his  cry  some- 
what resembling  that  heard  in  cases  of  tubercular  meningitis. 
The  pulse  was  imperceptible. 

We  immediately  performed  artificial  respiration,  together  with 
cervical  and  other  nerve  frictions ;  the  breathing  became  less 
laboured,  but  the  movements  of  the  legs  increased  and  spasmodic 
movements  of  the  ami  commenced.  The  spasmodic  movements 
of  the  head  were  now  such  that  the  head  was-turned  alternately 
to  both  sides,  not  only  to  the  left  as  before.  I  now  noticed  when 
patient  opened  his  eyes  that  the  left  pupil  was  larger  than  the 
right. 

At  6.45  p.m.  patient  was  still  profoundly  unconscious,  the 
spasmodic  movements  and  screaming  continuing.  We  took  him 
to  a  house  close  by  and  placed  him  sitting  up.  Every  few  seconds 
patient  rose  on  his  feet  with  a  scream  and  assumed  a  position  of 
opisthotonic  rigidity  ;  this  would  last  a  second  or  two  and  then  he 
would  collapse  into  the  chair  again.  A  wrist-drop  in  the  right  hand 
was  noticeable  for  the  first  time.  The  treatment  was  now  chiefly 
stimulatory  nerve  frictions. 

7.30  p.m.  Wrist-drop  disappeared,  patient  somewhat  quieter  ; 
pulse  very  weak,  so  rapid  that  it  could  not  be  counted,  and  very 
irregular.  Patient  was  driven  in  a  carriage  to  his  house,  and  on 
the  way  he  every  now  and  then,  after  a  preliminary  scream, 
assumed  a  position  of  opisthotonic  rigidity,  or  sat  up  for  a  few 
seconds,  collapsing  again  as  before. 

8  p.m.  Patient  arrived  home  and  we  set  him  in  an  armchair. 
The  spasms  of  the  body  and  extremities  were  getting  less,  except- 


DISEASES  OF  THE  NERVOUS  SYSTEM  459 

ing  m  the  head  ;  and  there  was  less  screaming.  Patient  was  still 
quite  unconscious.  Treatment  was  now  chiefly  directed  to  draw- 
ing blood  away  from  the  head. 

9  p.m.     Faint  gleams  of  returning  consciousness. 

10  p.m.  Patient  fairly  quiet ;  but  cardiac  action  feeble  and 
irregular. 

11  p.m.  Patient  quite  quiet.  Heart's  action  very  weak,  136 
per  minute,  irregular  and  intermittent.  Respiration  still  some- 
what laboured ;  many  bubbling  sounds  in  the  chest  plainly 
audible  at  a  considerable  distance  (even  ten  feet  away  in  the 
room  adjoining).  The  treatment  since  9.30  p.m.  had  been 
chiefly  heart  vibration  and  shaking.  It  was  necessary  to  main- 
tain treatment  over  the  heart  continuously ;  as  soon  as  it  was 
stopped  the  heart  became  very  irregular,  and  the  treatment  had 
to  be  resumed  at  once.  From  9.30  p.m.  to  1  a.m.  the  heart  could 
not  be  left  alone  for  more  than  five  minutes,  without  giving 
signs  of  speedy  failure. 

July  20. — 12  midnight.  Heart  treatment  was  gradually  given 
to  a  less  and  less  amount  from  now  onwards.  Pulse  126,  more 
regular. 

12.1-5  a.m.     Pulse  120,  still  very  weak. 

1  a.m.  Pulse  116,  weak,  more  regular.  Patient  opened  his 
eyes  when  his  name  was  called  very  loudly. 

2  a.m.  Patient  tried  to  speak  once  or  twice.  Pulse  108 ; 
heart  treatment  only  administered  every  few  minutes  for  a  minute 
or  two.  Patient,  who  had  been  sitting  in  an  armchair  till  now, 
was  put  to  bed. 

2.30  a.m.  Patient  had  turned  over  in  bed  twice  by  himself. 
Heart  treatment  only  very  occasionally. 

3  a.m.     Patient  recognised  his  wife.     Pulse  100,  regular. 

3.30  a.m.  Patient  suddenly  vomited  a  large  amount  of  coffee- 
coloured  liquid,  after  which  he  recovered  consciousness.  He 
remembered  nothing  since  he  fell  down  into  the  water,  and 
wondered  why  I  was  in  attendance. 

4.4.5  a.m.  Patient  quite  rational  again.  Pulse  85,  strong, 
regular.     I  ceased  treating  patient  and  went  home. 

During  the  afternoon  I  saw  patient  again.  He  was  weak  and 
sore  in  the  places  where  we  had  given  him  the  nerve  frictions, 
but  otherwise  was  fairly  well.  I  executed  some  movements  for 
the  lungs  and  heart. 


46o     ELEMENTS  OF   KELLGREN'S   MANUAL    TREATMENT 

July  21. — Appetite  normal.  Patient  went  for  a  short  walk. 
Treatment  at  home  once. 

July  22. — Treatment  at  home  once.  Patient  felt  very  well ; 
better  than  before  the  seizure. 

July  23. — Patient  walked  to  my  house  and  back  (distance 
about  one  mile  each  way).  Some  rheumatic  pain  was  present  in 
the  left  toe  and  shoulder. 

Treatment  henceforth  once  daily,  consisting  of : — Movements 
of  joints,  such  as  : — 

(1)  Half  lying  double  arm  rolling,  PP,  bending  and  stretch- 
ing, AE. 

(2)  Half  lying  double  leg  rolling,  PP,  flexion,  PA,  extension, 
AE. 

(3)  Half  lying  double  foot  rolling,  PP,  flexion,  AE,  extension, 
AE. 

Also  respiratory  movements,  stomach  exercise,  PP,  kidney 
treatment,  PP,  head  exercise,  PP,  &c. 

Progress. — The  pains  in  the  toe  and  shoulder  disappeared 
after  a  few  days,  and  after  appearing  in  other  joints  for  a  few 
days  more  finally  vanished. 

On  July  23  patient  returned  to  his  work  at  Huskvarna  factory. 

August  23. — Patient  felt  very  well  indeed,  much  better  than 
for  years  past.  He  had  had  no  rheumatic  pains  at  all  during 
the  last  ten  days.  He  had  during  the  time  under  treatment  got 
rid  of  a  slight  chronic  catarrh  of  the  lungs,  from  which  he  had 
suffered  all  his  life.     Treatment  finished. 

August,  1902. — Patient  still  keeping  very  well. 

A  case  of  "Gunshot  Injury  to  the  Musculo-Spinal  Nerve," 
treated  by  Henrik  Kellgren,  has  been  described  by  Owen  in  the 
Lancet  for  November  18,  1876,  pp.  709,  710.  In  the  same 
journal  for  December  3,  1876,  p.  806,  is  found  a  letter  from  Sir 
W.  H.  Broadbent,  stating  that  he  saw  the  case  before  and  after 
treatment,  and  certifying  to  the  speedy  recovery  that  took  place. 


CHAPTER  IX. 

DISEASES    OF    THE    LOCOMOTOR    SYSTEM. 
Chronic   Rheamatism. 

Case  1. 

Mr.  K.  N.,  builder,  aged  40,  came  under  the  manual  treatment 
on  November  9,  1900. 

Historij  of  present  illness.  —  Patient  thought  that  he  first 
began  to  suffer  from  rheumatic  pains  about  five  years  previously ; 
he  could  not  ascribe  any  particular  cause.  Since  that  time  he 
had  been  sufi'ering  from  pains  and  stiffness,  particularly  in  the 
shoulders,  back  and  hip-joints,  but  also  in  the  arms.  There  was 
difticulty  and  pain  on  movement  at  first,  although  a  good  deal  of 
movement  relieved  the  condition  for  the  time  being.  He  had 
never  been  very  bad,  and  had  never  had  to  stop  in  bed.  The 
rheumatic  symptoms  were  absent  during  the  warm  months  in  the 
summer  time,  but  always  returned  during  September  or  October, 
and  remained  until  the  following  summer.  Patient  had  never 
consulted  any  medical  man  about  his  rheumatism,  and  had  never 
taken  any  internal  or  external  remedies.  For  the  week  preceding 
November  8  patient  had  been  suffering  from  rheumatic  pains  in 
his  left  hip  and  right  shoulder.  On  November  8  he  became  very 
hot  over  some  work,  and  while  walking  home  thought  he  caught 
cold.  The  pains  mentioned  became  much  worse  in  the  course  of 
the  night ;  he  slept  very  badly,  perspired  a  good  deal  and  thought 
he  had  some  fever.  The  next  morning,  November  9,  he  had 
pains  in  his  back,  both  arms,  and  both  hips,  especially  the  left. 
The  left  hip  was  so  painful  as  to  prevent  him  walking.  Patient 
drove  from  his  house  to  mine,  distance  two-thirds  of  a  mile. 

Examination. — Patient  walked  with  the  help  of  two  sticks  and 
tried  to  use  his  left  hip  as  little  as  possible.  He  complained  of 
great  pain  in  that  joint,  also  in  the  spinal  muscles  and  both 
shoulder-joints.  Pressure  over  the  hip-joint,  a  blow  on  the  foot 
with  patient  lying  down  and  his  knee-joints  extended,  and  any 


462     ELEMENTS   OF   KELLGREN'S    MANUAL    TREATMENT 

attempted  movement  of  tlie  affected  joints  greatly  increased  the 
pain.  There  was  no  fever ;  the  pulse  while  patient  was  lying 
down  was  88  per  minute. 

Treatment. 

Vibrations  followed  by  passive  flexions,  extensions,  &c.,  at  the 
affected  joints.  A  great  amount  of  traction  was  necessary,  or 
the  patient  would  not  have  endured  the  exercises  because  of  the 
pain ;  the  movements  had  to  be  executed  through  a  very  small 
radius  at  first,  and  their  extent  gradually  increased.  In  this  way, 
after  about  ten  minutes  or  so,  I  could  administer  passive  leg  roll- 
ing with  very  little  pain  to  the  patient.  I  also  executed  move- 
ments at  the  other  joints  of  the  body,  stomach  exercise  and 
kidney  frictions,  PP,  forwards  lying  back  exercise,  PP. 

Progress. — After  the  first  treatment  patient  was  so  much 
benefited  that  he  could  walk  home. 

November  10. — General  condition  better.  No  pain  except  in 
left  hip.     Treatment  as  before  ;  patient  better  after  it. 

November  11. — No  treatment. 

November  12. — No  pain  in  left  hip  or  anywhere  else.  Treat- 
ment. 

November  15.  —  Treatment  finished.  No  rheumatic  pains 
anywhere. 

During  the  evening  of  the  15th,  patient  worked  out  in  the 
open  air  in  cold  weather,  and  became  wet  through  with  perspira- 
tion.    No  bad  effects  resulted,  however. 

March,  1902. — No  return  whatever  of  the  pains. 

Case  2. 

E.  A.,  male,  aged  35,  came  under  the  manual  treatment  on 
August  18,  1902. 

History  of  j] resent  illness. — Patient  had  for  years  past,  every 
now  and  then  had  rheumatic  pains  in  his  legs  and  arms,  although 
until  the  present  attack  never  so  badly  as  to  prevent  his  working. 
Patient  had  never  taken  any  internal  or  external  remedies  for 
these  pains.  About  July  15  he  was  caught  in  the  rain,  and 
during  the  same  evening  felt  pain  and  stiffness  in  his  lumbar 
region,  aggravated  during  flexion  forwards  of  the  trunk.  Kheu- 
matic  pains  in  the  arms  and  legs,  which  had  been  present  to 
a  slight  extent  all  the  previous  week,  became  intensified.     After  a 


DISEASES  OF  THE  LOCOMOTOR  SYSTEM  463 

lew  days  there  was  considerable  difficulty  in  walking,  and  sleep 
was  disturbed  by  the  pains  at  night.  His  condition  remained 
about  the  same  until  August  15,  when  he  was  attacked  by  shiver- 
ing and  perspiration,  and  his  rheumatic  pains  were  much  worse. 
He  felt  very  ill  and  had  to  cease  work ;  he  went  home  and  stopped 
m  bed  all  day,  also  during  the  following  day.  On  August  18  he 
had  so  far  recovered  that  he  could  walk  to  my  villa  for  treat- 
ment, although  this  caused  him  a  good  deal  of  pain. 

Examination. — Patient  walked  with  a  limp  in  his  right  leg. 
Great  tenderness  to  pressure  over  the  right  gluteal  region  round 
about  the  great  trochanter,  along  the  outer  side  of  the  thigh,  and 
in  both  lumbar  regions.  Pain  and  stiffness  on  movement  of  the 
right  leg,  especially  during  excentric  extension  and  during  flexion 
forwards  of  the  trunk.  Patient  also  complained  of  some  pain  in 
the  arms  and  left  leg,  although  no  specially  tender  spots  could  be 
determined.     Temperature  99 '2°. 

Treatment.  —  Kneading  of  the  affected  parts,  movements  at 
joints  to  exercise  them,  forwards  lying  back  exercise,  stomach 
exercise,  and  kidney  frictions.  . 

Progress.— On  August  -I'l  patient  was  so  much  better  that  he 
resumed  work.  On  August  23  all  the  pain,  stiffness  and  tender- 
ness had  entirely  disappeared,  and  patient  said  that  he  felt  quite 
well  and  strong.     Treatment  finished. 

September  14. — No  return  of  the  pains. 

It  will  be  observed  that  in  both  the  foregoing  cases  neither  of 
the  patients  had  ever  tried  any  remedies  for  their  rheumatism 
previous  to  their  coming  under  the  manual  treatment.  To  this 
fact  I  attribute  the  rapid  result.  My  experience  has  gone  to  show 
that  the  more  previous  medicinal  treatment  rheumatic  cases  have 
had  the  harder  they  are  to  cure  by  the  manual  treatment.  Per- 
sonally, I  should  hold  out  more  prospect  of  cure  to  a  long-stand- 
ing case  of  rheumatism  that  had  never  received  any  treatment 
than  to  a  similar  case  of  shorter  duration  which  had  undergone  a 
good  deal  of  medication. 

Case  3. — Lumbago. 

In  fresh  cases  of  luinbago,  in  which  spasmodic  contraction  of 
muscles  seems  to  play  an  important  part,'  relief  can  sometimes 

'  Cf.  Georgii,  "  Kiuetic  Jottiugs,"  1880,  p.  175. 


464     ELEMENTS   OF  KELLGREN'S  MANUAL    TREATMENT 

be  produced  at  once  by  vibrations,  followed  by  frictions  on  the 
affected  muscles. 

In  old  cases,  however,  where  the  condition  appears  to  be  more 
an  inflammatory  process  of  the  whole  or  part  of  the  erector  spinse, 
the  treatuient  is  as  follows  :  — 

(1)  Manipulations  such  as  vibrations,  frictions,  hackings,  beat- 
ings over  the  affected  muscles. 

(2)  Exercises  during  which  the  affected  muscles  are  alter- 
nately passively  elongated  and  shortened. 

(3)  Exercises  during  which  the  patient  has  to  put  the  affected 
muscles  into  excentric  and  concentric  contraction. 

(4)  Exercises  to  stimulate  the  nerves  to  the  affected  muscles. 

(5)  Exercises  to  benefit  the  constitution  as  a  whole. 

S.,  aged  27,  employed  in  the  iron  founding  department  in 
the  factory  at  Huskvarna,  came  under  the  manual  treatment 
on  May  29,  1900. 

History  of  present  illness. — He  said  that  he  first  began  to  feel 
stiff  in  his  back  about  a  year  previously ;  about  six  months  later 
this  began  to  cause  him  serious  inconvenience.  A  medical  man 
he  consulted  diagnosed  rheumatism  and  gave  him  powders. 
These  did  not  help  him  at  all,  and  he  got  worse  and  worse. 
Early  in  May  he  ceased  work  for  a  few  days,  but  the  rest  did 
him  no  good ;  after  this  he  tried  again  to  work,  but  was  com- 
pelled to  stop  after  a  few  days.  Another  medical  man  who 
was  consulted  diagnosed  lumbago,  and  recommended  gymnastic 
treatment. 

Exaininatio)!.  —  The  spinal  muscles  on  both  sides  from  the 
sacrum  up  to  the  sixth  dorsal  vertebra  were  very  hard  and  resis- 
tant and  painful  on  manipulation  ;  even  slight  flexion  of  the 
trunk  forwards  or  sideways  caused  the  patient  much  pain,  as 
did  any  other  movements  involving  active  contraction  or  stretch- 
ing in  the  muscles  referred  to. 

Treatment. 

(1)  Kide  sitting  trunk  flexion,  PK,  extension,  AR. 

(2)  Stretch  stride  standing  bending  forwards,  PA. 

(3)  Leg  lean  stride  standing  trunk  flexion,  PR,  extension,  AE. 

(4)  Side  lying  leg  lifting,  AH,  pressing  down,  PR. 
(-5)  Lying  double  leg  flexion,  AE,  extension,  PR. 


DISEASES  OF  THE  LOCOMOTOR  SYSTEM  465 

(6)  Lying  leg  flexion,  PR,  extension,  AR. 

(7)  Hip  lean  walk  standing  lateral  flexion,  PR,  extension,  AE. 

(8)  Reach  grasp  step  standing  knee  flexion  and  extension,  PA, 
sacral  beating,  PP. 

(9)  Forwards   lying   back  exercise,  PP,  with  extra  frictions 
over  the  most  painful  muscles,  PP. 

(10)  Half  lying  stomach  exercise,  PP. 

Progress. — Patient  felt  better  immediately  after  the  first  treat- 
ment, and  he  continued  to  improve  mitil  June  16,  when  he  caught 
a  feverish  cold.  He  was  treated  at  home  on  June  16,  17,  and 
18.  On  June  19  he  was  able  to  come  to  me  again,  and  the 
only  pain  he  felt  was  over  the  left  side  of  the  sacrum  when  the 
muscles  of  this  region  were  placed  into  action.  On  June  80  he 
was  practically  well ;  on  July  2  he  began  to  do  some  light  work 
at  the  factory.  He  continued  the  treatment  a  few  days  longer  to 
prevent  relapse,  after  which  he  left  me  quite  cured,  and  shortly 
afterwards  worked  again  in  the  iron  founding  department. 
April,  1902. — No  return  of  the  symptoms. 


Case  4. — Lumbago. 

I.,  aged  35,  worker  in  Huskvarna  factory,  came  under  the 
mamial  treatment  on  October  3,  1899. 

History  of  present  illness. — -Patient  had  been  suffering  on  and 
off  for  five  years  from  lumbago,  which  had  been  a  good  deal 
worse  the  last  six  months. 

Examination. — There  was  considerable  pain  during  any  move- 
ment entailing  flexion  of  the  trunk ;  and  on  trying  to  get  up  after 
sitting  still,  sharp  stabbing  pains  were  felt  in  the  lumbar  region. 
The  muscles  of  the  back  from  the  sacrum  to  about  the  second 
dorsal  vertebra  were  hard,  resistant,  and  tender  to  pressure. 

The  treatment  was  on  the  same  lines  as  in  the  foregoing 
case,  and  was  administered  daily  until  November  3,  1899,  when 
patient  left,  being  cured,  and  having  no  more  pain  or  stiffness  of 
any  kind. 

August,  1900. — Patient  said  that  during  the  past  winter  he 
had  occasionally  felt  slight  pain  on  movements  entailing  strong 
flexion  forward  of  the  trunk,  otherwise  he  had  been  quite  well 
ever  since  the  treatment  finished. 
30 


466     ELEMENTS    OF    KELLGREN'S    MANUAL    TREATMENT 

Case  5. — Lumbago. 

J.  O.,  male,  aged  38,  came  under  the  manual  treatment  on 
February  9,  1901. 

History  of  j'^'esent  illness. — Patient  had  been  suffering  from 
pains  in  the  lumbar  region  for  about  three  weeks,  brought  on,  he 
said,  by  catching  cold. 

Examination. — There  was  tenderness  over  the  back  on  both 
sides  from  the  sacrum  to  the  tenth  dorsal  vertebra.  There  was 
difficulty  in  bending  the  trunk  forward,  and  in  any  other  move- 
ment involving  the  lumbar  and  sacral  spinal  muscles. 

Treatment.  —  Commencing  with  vibrations  on  the  affected 
muscles,  I  increased  the  strength  of  the  manipulation  until  they 
became  strong  frictions.  These  at  first  caused  pain,  but  not 
afterwards.  The  patient  was  then  given  stretch  stride  standing 
bending  forwards,  PA,  with  hacking  over  the  lumbar  region,  after 
which  he  said  that  the  pain  had  entirely  disappeared. 

August,  190'2. — No  return  of  the  symptoms. 


Partial  Rupture  of  the  Gastrocnemius  Muscle. 

Lieutenant  E.  C.  F.,  student  at  the  Central  Gymnastic  Insti- 
tute, came  under  the  manual  treatment  on  October  21,  1898. 

History  of  present  condition.  —  On  October  13,  1898,  after 
having  finished  an  hour's  pedagogical  gymnastics,  patient  was 
seized  with  sudden  pain  in  the  right  calf.  The  pain  increased  in 
amount,  and  the  day  after  the  seizure  patient  noticed  that  there 
was  considerable  swelling  over  the  middle  of  the  calf,  and  that 
the  part  was  discoloured,  being  dark  blue.  He  was  able  to  walk 
a  little,  though  with  much  difficulty  and  pain,  and  came  to  the 
cliuique  at  the  Institute. 

Examination. — The  middle  third  of  the  calf  was  deeply  dis- 
coloured from  extravasated  blood,  and  there  was  considerable 
swelling.  There  was  great  tenderness  along  the  inner  border 
of  the  gastrocnemius  and  soleus  in  the  middle  third  of  the  calf, 
and  the  affected  part  was  hotter  than  normal.  Passive  extension 
of  these  muscles  caused  pain.  Prof.  Murray,  who  was  consulted, 
diagnosed  ruptura  musculi  in  the  right  calf. 

Treatment  and  progress. — The  patient  did  not  come  under  my 


DISEASES  OF   THE    LOCOMOTOR   SYSTEM  467 

care  at  once,  but  was  treated  by  massage,  fat  being  first  duly 
rubbed  on  the  part  manipulated.  This  was  continued  daily  from 
October  14  to  20  inclusive,  with  very  little  or  no  benefit.  On 
October  21  I  treated  the  case  for  the  first  time.  I  chiefly 
administered  vibrations  over  the  part,  nerve  frictions  on  the 
internal  popliteal  nerve,  and  running  vibrations  and  frictions 
given  centripetally.  On  October  22  patient  was  much  better, 
and  had  but  little  difficulty  in  walking.  No  treatment  was 
administered  on  October  28.  On  October  24  the  pain  had 
almost  completely  disappeared,  and  patient  fenced  for  an  hour 
with  only  slight  inconvenience.  The  next  day  he  practicall}^  felt 
no  pain.  I  continued  treating  him,  however,  until  October  81, 
on  which  day  the  last  of  the  extravasation  and  discolouration  dis- 
appeared. 

April,  1899. — Calf  muscles  quite  normal. 


Chronic  Synovitis,  &c. 

(From  notes  taken  by  Dr.  A.  Moller  and  myself.) 

B.  J.,  male,  aged  25,  came  under  the  manual  treatment  on 
February  14,  1900,  suffering  from  chronic  synovitis  in  the  right 
knee,  chronic  pains  in  the  abdomen,  chronic  laryngitis,  headache 
and  general  depression. 

History  of  present  condition. — About  two  years  previously  his 
right  knee  had  begun  to  be  stiff  and  to  hurt  him  ;  it  got  better 
after  some  time,  but  then  worse  again.  He  went  on  alternately 
getting  better  and  worse,  and  then  became  steadily  worse  for 
three  months  before  he  came  to  me.  At  intervals,  when  his 
state  was  at  its  worst,  he  was  unable  to  stand  on  his  right  leg 
with  the  left  foot  lifted  off  the  ground,  and  much  pain  was  caused 
on  walking.  For  about  fourteen  months  he  had  suffered  almost 
constantly  from  pains  in  his  epigastric  and  left  hypochondriac 
regions,  and  the  slightest  touch  over  these  parts  often  hurt  him 
very  much  ;  sometimes  he  could  hardly  bear  having  his  clothes 
on.  At  Easter,  1899,  he  consulted  a  medical  man,  who  diag- 
nosed gastric  catarrh  and  prescribed  Carlsbad  water  and  castor 
oil.  Patient  felt  somewhat  better  during  the  period  he  took  these 
remedies,  which  was  one  month  ;  but  as  soon  as  he  left  off  he  was 
just  as  bad  again.     Often  when  the  pain  in  his  abdomen  was  very 


468       ELEMENTS   OF   KELLGREN'S    MANUAL    TREATMENT 

bad,  relief  was  to  some  extent  obtained  by  getting  a  friend  to 
give  him  a  kind  of  abdominal  massage 

Every  now  and  then  the  patient  became  very  depressed  and 
could  not  be  cheered  up.  A  chronic  laryngitis  had  been  present 
for  some  years ;  it  had  been  rather  worse  during  the  last  few 
months. 

Examinatio)i. — Patient  could  not  stand  on  the  right  leg  and 
lift  up  the  left  one  without  considerable  pain  in  the  right  knee ; 
he  walked  in  a  somewhat  limping  way,  hurrying  over  the  time  he 
had  to  support  himself  with  his  right  leg.  He  could  not  flex 
the  affected  knee  further  than  a  right  angle  without  very  much 
pain,  and  even  flexing  it  so  far  hurt  him.  There  was  a  very 
tender  spot  just  internal  to  the  right  patella.  The  muscles  of  the 
abdomen  were  contracted  and  hard,  especially  in  the  subcostal 
triangle,  where  there  was  great  tenderness  to  touch. 


Treatment. 

{!)  Eeach  grasp  step  standing  knee  flexion  and  extension,  PA, 
right  knee-joint  vibration  and  kneading,  sacral  beating,  PP. 

(2)  Stretch  grasp  standing  drawing  forwards,  PP,  shaking  of 
the  pit  of  the  stomach,  PP. 

(3)  Sitting  trunk  extension  and  flexion,  PA  ;  sit  lying  right 
knee  extension  and  flexion,  PP,  extension,  AE,  flexion,  PE. 

(4)  Stretch  lean  toe  standing  double  knee  bending,  PA. 

(.5)  Heave  grasp  standing  chest  clapping,  side  shaking,  PP. 

(6)  Stretch  grasp  toe  standing  hanging,  breathing,  PA. 

(7)  Forwards  lying  back  exercise,  PP,  right  leg  flexion,  PP, 
raising,  AE. 

(8)  Stride  sit  kneeling  raising,  AE. 

(9)  Half  lying  double  leg  rolling,  PP,  flexion,  PA,  extension, 
AE,  right  knee-joint  kneading,  PP. 

(10)  Half  lying  stomach  exercise,  PP. 

(11)  Sitting  head  and  throat  exercises,  P.P. 

Progress  — March  14. — Patient  said  that  his  leg  was  much 
better ;  during  ordinary  movements  there  was  hardly  any  pain  ; 
sharp  pain  only  came  on  with  extreme  flexion.  The  tenderness 
over  the  spot  internal  to  the  patella  was  much  less.  Patient,  how- 
ever, very  soon  became  tired  in  the  aflected  knee  when  walking. 


DISEASES    OF    THE    LOCOMOTOR   SYSTEM  469 

The  pains  in  tlae  abdomen  had  disappeared;  patient  said  that  his 
digestion  had  not  been  in  such  good  order  as  now  for  some  years. 
The  abdominal  muscles  were  less  tense,  and  there  was  but  little 
tenderness  in  the  epigastrium.  Patient  no  longer  suffered  from 
headaches.     The  laryngitis  was  better. 

April  7. — The  right  knee  had  continued  to  improve,  and 
became  less  tired  on  exertion. 

April  14. — The  only  abnormal  sj'inptom  in  the  right  knee  was 
a  feeling  of  fatigue,  which,  however,  only  came  on  after  a  con- 
siderable amount  of  walking  Patient  said  that  his  digestion  was 
splendid.  He  was  free  from  headaches;  the  depression  had  left 
him,  and  he  was  continually  in  a  cheerful  state  of  mmd.  The 
laryngitis  was  slightly  better.     Treatment  finished. 

July  18,  1900. — Patient  was  still  feeling  very  well,  although 
still  liable  to  slight  stiffness  in  the  right  knee  after  much  walking. 

July,  1902. — Condition  of  knee  unchanged. 


Abscess  in  the  Antrum  of  Highmore. 

Mrs.  A.,  aged  48,  came  under  the  manual  treatment  on  April 
'21,  1900. 

Historij  of  present  condition.  —  Patient  noticed  on  April  12, 
1900,  that  her  nose  felt  stuffy  on  the  right  side,  and  that,  on 
getting  up,  a  quantity  of  bad-smelling  yellowish  matter  came 
out  of  her  nostril ;  each  subsequent  morning  a  great  deal  of  dis- 
charge came,  as  patient,  in  consequence  of  weak  cardiac  action, 
always  slept  on  her  right  side.  Leaning  her  head  over  to  the  left 
side  usually  induced  a  discharge,  or  if  already  in  progress  it  was 
increased  in  amount. 

Examination. — Patient  complained  of  continued  pain  in  the 
right  supramaxillary  region,  and  discharge  from  the  nose.  On 
Hexing  the  head  laterally  to  the  left,  some  thick  yellowish  bad- 
smelling  pus  appeared  from  the  nostril.  The  right  cheek  was 
red  and  tender  to  touch,  and  there  was  pain  on  slight  percussion. 

Treatment. — The  special  treatment  for  the  antral  abscess  was 
as  follows  : — 

Sitting  right  superior  maxillary  vibration  with  the  patient's 
head  flexed  to  the  left ;  vibrations  on  the  root  of  the  nose ;  right 
trigeminal  nerve  frictions  ;  right  facial  nerve  frictions. 


4;o     ELEMENTS   OF    KELLGREN'S    MANUAL   TREATMENT 

Prof/iess. — April  '2o. — Discharge  less.  Less  tenderness  over 
the  clieek. 

April  24. — No  pain  in  cheek  whatever. 

May  28. — Patient  had  been  feeling  very  vi^ell  dnrin<,'  the  last 
month ;  the  discharge,  however,  had  remained  almost  constant  in 
quantity.     On  this  day  it  was  thinner  than  usual. 

June  2. — Discharge  still  thinner. 

June  4. — Discharge  looked  like  water. 

June  5. — No  discharge,  no  tenderness.  Nose  apparently 
normal. 

June  16. — Treatment  finished.  No  discharge  or  tenderness 
since  the  5th. 

August,  1902. — No  return  of  discharge. 


Dislocation  of  the  right  Humerus. 

(From  notes  by  Dr.  A.  Moller  and  myself.) 

S.,  aged  48,  worker  in  Huskvarna  factory,  came  under  the 
manual  treatment  on  November  15,  1899. 

History  of  preaent  condition. — Patient  had  on  three  previous 
occasions  dislocated  his  right  humerus,  i.e.,  (1)  in  1886 ;  (2)  in 
1896,  when  chloroform  was  used  in  order  to  replace  it ;  and  (3) 
in  November,  1898.  The  present  dislocation  occurred  at  9  a.m. 
on  November  15. 

Examination. — 10  a.m.  same  day.  There  was  dislocation 
forwards  of  the  right  humerus  ;  the  right  arm  hung  limp  and 
useless,  there  was  a  depression  below  the  acromion,  and  the  elbow- 
projected  backwards.  The  head  of  the  humerus  could  be  felt 
lying  under  the  pectoralis  major.  There  were  no  signs  of 
swelling.  There  was  very  much  pain  in  the  region  of  the  joint, 
and  patient  was  pale  and  shivering. 

Treatment.  —  The  dislocation  was  reduced  as  follows: — The 
arm  was  lifted  high  up  into  stretch  position ;  then,  asking  the 
patient  to  resist  as  much  as  possible,  I  performed  adduction  of 
the  right  arm  with  traction  away  from  the  shoulder,  bringing  the 
whole  limb  somewhat  forwards  as  I  went.  While  doing  this  Dr. 
Moller  pressed  in  the  head  of  the  bone.  The  object  of  this  pro- 
cedure was :  first,  by  traction  to  bring  the  head  of  the  humerus 
over  the  rent  in  the  capsule  ;  the  exertions  of  the  patient  to  resist 


DISEASES    OF    THE   LOCOMOTOR  SYSTEM  471 

caused  the  deltoid  to  act  as  a  fixed  point  of  a  lever,  one  end  of 
which  was  from  that  point  to  my  grasp  on  the  forearm,  and  the 
other  from  that  point  to  the  head  of  the  humerus.  The  bringing 
downwards  and  forwards  of  the  distal  end  of  the  arm  caused  the 
head  of  the  humerus  to  pass  upwards  and  backwards  into  the 
capsule  again. 

Immediately  after  reduction  of  the  dislocation  the  following 
movements  were  administered  on  the  joint  : — Vibrations  to 
prevent  inflammation  :  duplicate  movements  at  the  shoulder- 
joint  in  order  to  exercise,  and  thus  strengthen,  the  muscles 
weakened  by  the  displacement,  taking  care  to  avoid  those 
which  would  cause  the  head  of  the  humerus  to  pass  downwards, 
i.e.,  such  movements  as  the  following  were  given  : — 

Swim  sitting  right  elbow  pressing  downwards,  PR. 

Sitting  right  forearm  flexion,  AR,  extension,  PR. 

Sitting  right  arm  traction  sideways,  PP,  followed  by  the 
patient  trying  to  draw  his  arm  towards  himself,  with  AR. 

General  constitutional  treatment  was  added.  Patient  was 
told  to  move  his  arm  as  much  as  he  liked,  taking  care  only  to 
avoid  movements  of  abduction,  and  was  sent  home  without  any 
bandage  or  fixation  being  applied. 

Progress. — November  16. — Patient  slept  very  well ;  there  was 
only  very  slight  pain  in  the  shoulder,  which  was  not  increased 
during  movement. 

November  18.  —  Patient  could  lift  his  arm  to  almost  the 
perpendicular  {i.e.,  stretch  position).     No  pain. 

November  21. — Some  extra  strengthening  exercises  were  added 
to  the  treatment.  Patient  went  back  to  work  and  did  nine  and 
a  half  hours  of  metal  polishing. 

November  28. — Patient  had  been  at  work  all  the  week,  and 
said  that  his  arm  felt  quite  well. 

December  14. — Patient  continued  treatment  until  this  day. 
He  left  with  his  shoulder-joint  quite  normal.  In  addition  to  this, 
his  digestion  was  much  improved  by  the  stomach  exercise  which 
he  had  received  every  day. 

Patient's  shoulder  remained  quite  well  until  March  31,  1900, 
when  on  lifting  up  a  weight  with  his  right  arm,  he  redislocated 
it  in  the  same  manner.  He  immediately  came  to  Dr.  Moller 
and  myself,  who  reduced  the  dislocation  and  treated  it  in  the 
same  way  as  on  the  first  occasion.  After  treatment  hardly  any 
pain.     No  bandage  was  used. 


472      ELEMENTS  OF  KELLGREN'S  MANUAL  TREATMENT 

April  1. ^Slight  pain  anteriorly  in  the  front  of  the  shoulder. 
Active  and  duplicate  movements  executed. 

April  'A. — Treatment  for  the  last  time.  Patient  normal.  He 
returned  to  work  again. 

March,  190"2. — There  had  been  no  further  dislocation. 


Dislocation  of  left  Humerus. 

E.  S.,  female,  aged  8j,  came  under  the  manual  treatment  on 
July  7,  1902. 

History  ofjjresent  condition'. — The  day  previously  patient  had 
been  playing  about ;  while  running  after  another  child  she  fell 
down  on  her  left  arm  and  hurt  herself  very  much.  She  screamed 
with  pain,  which  she  located  in  the  left  shoulder.  She  kept  her 
left  arm  still,  and  any  attempt  to  move  it  only  caused  increase  in 
the  pain.  Her  mother  was  unable  to  undress  her  in  consequence 
and  she  went  to  bed  with  her  clothes  on.  She  slept  very  badly 
and  the  following  day  complained  of  still  more  pain. 

Examination. — I  first  saw  patient  at  4  p.m.  on  July  7.  The 
left  arm  hung  limp  ;  movements  of  the  shoulder  were  very 
painful  and  limited  to  a  slight  amount  of  abduction.  The 
shoulder  was  flattened  and  there  was  a  depression  below  the 
acromion.  The  head  of  the  humerus  could  be  felt  anteriorly 
below  the  coracoid  process,  and  the  humerus  hung  so  that  the 
elbow  was  more  posteriorly  than  normal,  and  somewhat  away 
from  the  trunk. 

Treatment. — Reduction  was  effected  fairly  easily  with  very 
little  pain  by  means  of  abduction  to  a  right  angle  combined  with 
traction  away  from  the  trunk,  and  then  adduction  with  PE  while 
the  head  was  pressed  in.  Immediately  afterwards  the  following 
movements  for  the  shoulder  were  executed  : — 

(1)  Sitting  left  arm  circling,  PP. 

(2)  Sitting  left  shoulder  vibration  and  muscle  kneading,  PP. 

(3)  Sitting  left  arm  traction  sideways,  PP,  drawing  arm 
towards  trunk,  AR. 

(4)  Sitting  left  arm  abduction  to  right  angle,  PP,  adduction, 
PR. 

No  bandage  or  fixation  was  used.  Patient  left,  feeling  no  pain 
whatever,  and  could  be  seen  to  swing  her  left  arm  backwards  and 
forwards  as  usual  when  walking. 


DISEASES    OF    THE   LOCOMOTOR    SYSTEM  473 

Progress. — Jul)'  8. — No  pain.  No  swelling.  Movements  of 
arm  quite  free.  Abduction  through  135°,  PA,  and  the  reverse 
movement,  PR,  was  performed. 

Jul}'  9. — Patient  able  to  perform  abduction  through  180°. 

July  11. — Movements  quite  normal.  No  pain  or  swelling. 
Shoulder  normal.     Treatment  finished 

October,  1902. — Shoulder  had  continued  quite  normal. 


CHArTER   X. 

DISEASES    OF    THE     GENITO  -  URINARY    ORGANS 
AND     LABOUR. 

Sudden  Incontinence  of  the  Bladder. 

G.  J.,  female,  aged  1'2,  came  under  the  manual  treatment  on 
December  2,  1900. 

History  of  present  illness. — Patient  had  had  cystitis  two  years 
previously.  During  December  1,  1900,  sudden  incontinence  of 
the  urine  set  in  without  any  apparent  cause,  and  the  urine  ran 
incessantly  the  whole  day  until  patient  went  to  bed,  when  the 
incontinence  ceased.  On  trying  to  sit  up,  or  while  performing 
any  movement  requiring  exertion,  the  urine  flowed  again. 
Patient  did  not  sleep  well,  and  on  December  2  the  incontinence 
again  came  on  as  before.     I  was  sent  for  at  11  a.m. 

Examination. — Nothing  objective  could  be  made  out,  except- 
ing that  patient's  urine  was  discharged  involuntarily  on  trying 
to  sit  up  in  bed,  and  on  exertion.     The  urine  itself  was  normal. 

Treatment  and  progress. —  I  administered  suprapubic  vibra- 
tions, frictions  on  the  umbilicus  and  sacral  nerves,  and  stomach 
exercise.  At  their  close  patient  could  sit  up  and  move  with- 
out the  urine  flowing.  She  got  up,  and  the  incontinence  did 
not  return. 

March,  1902. — No  return  of  the  incontinence  had  taken  place. 

Menorrhagia. 

A.  L.,  aged  27,  domestic  servant,  came  under  the  manual 
treatment  on  May  9,  1902. 

History  of  present  condition. — -Patient  enjoyed  good  health 
until  1891,  when  at  the  age  of  16,  menstruation  of  the  thirty- 
day  type  commenced,  and  ever  since  the  third  time  of  its  onset 
it  had  lasted  for  nine  days,  during  which  the  discharge  was  very 
profuse.  This  caused  her  to  become  weak  and  anemic,  and  she 
suffered  continually  from  headache,  which  was  very  bad  indeed 


DISEASES  OF  THE  GENITO-URINARY  ORGANS,  &c.      475 

during  her  periods.  In  spite  of  various  internal  remedies  (iron, 
quinine,  &c.),  the  condition  liad  persisted  unchanged. 

Examination. — Patient  looked  very  anaemic  and  pale,  although 
she  had  not  the  typical  chlorotic  facies.  On  examination  there 
was  nothing  objective  beyond  tenderness  over  both  ovaries, 
especially  on  the  left  side.  Internal  examination  not  made. 
There  was  no  constipation ;  heart  and  lungs  were  healthy. 

The  last  period  of  menstruation  was  from  April  30  to  May  8. 

Treatiiicnf. 

(1)  Half  lying  double  foot  rolling,  PP,  flexion  and  extension, 
AK. 

("2)   Stretch  stride  standing  bending  forwards,  PA. 

(3)  Forwards  lying  back  exercise,  PP. 

(4)  Reach  grasp  stoop  fall  standing  double  elbow  flexion  and 
extension,  PA,  shoulder  hacking,  PP. 

(5)  Sit  lying  knee  extension  and  flexion,  PP,  extension,  AR, 
flexion,  PR. 

(6)  Ride  sitting  alternate  rotation,  AR,  ringing,  PP. 

(7)  Reach  grasp  step  standing  knee  flexion  and  extension, 
PA,  sacral  beating,  PP. 

(8)  Half  lying  leg  rolling,  PP,  flexion,  PA,  extension,  AR. 

(9)  Crook  half  lying  double  knee  abduction,  AR,  adduction, 
PR. 

(10)  Half  lying  stomach  exercise,  ovary  vibrations,  PP,  sacral 
nerve  frictions,  PP. 

No  exercises  were  omitted  during  the  menstrual  periods,  as 
depletion  of  the  pelvic  organs  was  aimed  at. 

Progress. — May  30. — Very  little  headache  since  the  treatment 
commenced ;  general  condition  stronger.  Menstruation  began 
this  day. 

June  4.  —  Menstruation  ceased  after  having  lasted  only  six 
days  ;  less  headache  meanwhile  than  usual. 

June  30. — No  headache  at  all  since  June  4.  Patient's  anaemic 
look  was  almost  gone,  and  she  said  that  she  felt  quite  well  and 
strong.     Menstruation  commenced  to-day. 

July  .5.  —  Menstruation  ceased,  again  having  lasted  only  six 
days.  Very  slight  headache  during  the  third  and  fourth  days, 
otherwise  none. 

July  9. — Treatment  finished.     Patient  normal,  excepting  for  a 


476    ELEMENTS   OF  KELLGREN'S  MANUAL   TREATMENT 

slight  amount  of  teiideniess  ovei'  tlie  left  ovary  ;  tliat  on  the  rif^ht 
side  had  quite  disaj^peared. 

Septemher  16,  190'2. — I  heard  from  patient's  mother  that 
menstruation  had  lasted  for  only  six  days  on  the  last  two  occa- 
sions. 

Threatening  Mammary  Abscess- 
Mrs.  C,  aged  28,  came  under  the  manual  treatment  on 
October  27,  1901. 

History  of  present  condition. — Patient  was  delivered  of  her 
first  child  on  October  13,  1901 ;  the  presentation  was  an  E.  0.  P. 
and  the  labour  was  normal.  On  October  17  patient  was  up 
and  about,  and  I  ceased  attending  her  on  October  24.  Patient's 
lactation  was  normal  until  October  27,  when  she  slept  badly  and 
had  much  pain  and  sense  of  weight  in  the  right  mamma.  I  was 
sent  for  in  the  morning. 

Examination — The  right  mamma  was  indurated,  swollen, 
somewhat  red,  painful,  and  extremely  tender  in  three  spots,  one 
near  the  nipple,  one  in  the  outer  upper  quadrant,  and  one  in  the 
outer  lower  quadrant.  She  had  had  several  rigors,  and  said  she 
felt  ill.     Temperature  102-6°,  pulse  129. 

Treatment.— Vibrations  over  the  mamma,  specially  the  tender 
spots ;  expression  of  the  milk  by  means  of  suction  vibrations ; 
frictions  on  the  descending  cervical,  anterior  thoracic,  and  fourth 
to  sixth  intercostal  nerves ;  constitutional  exercises.  At  the 
close  she  felt  better,  and  had  much  less  pain  and  tenderness. 

Progress. — October  28. — Morning.  Patient  had  slept  fairly 
well.  Some  redness  and  tenderness.  Temperature  1016°,  pulse 
104.  Treatment.  Afternoon.  Temperature  101°,  pulse  98. 
Treatment 

October  29. — Morning.  Only  slight  tenderness  left.  Temper- 
ature 97°,  pulse  78.     Treatment  only  once  during  the  day. 

October  30.  —  No  tenderness.  Mammary  gland  normal. 
Treatment  for  the  last  time 

(The  temperatures  were  all  taken  in  the  mouth). 

September,  1902. — No  return  of  the  symptoms. 

Labour. 

Mrs.  Q.,  aged  36,  came  under  the  manual  treatment  on  May 
11,  1900. 


DISEASES  OF  THE  GENITO-URWARY  ORGANS,   &-€.      477 

Previous  history. — Patient  had  previously  two  children,  both 
girls  ;  the  first  born  on  August  8,  1894,  the  second  on  April 
25,  1897.  Both  labours  were  normal,  the  first  lasting  about 
fourteen  hours ;  the  second  about  seven. 

Present  labour. — Commenced  at  5  p.m.  on  Maj-  11;  at 
9.4-5  p.m.  I  was  sent  for.  Patient  was  standing  up  and  walking 
about,  with  pains  coming  about  every  five  minutes ;  she  was 
already  in  the  second  stage.  Vaginal  examination. — Cervix  fully 
dilated,  head  presentation  in  the  L.  0.  A.  position.  The  vertex 
about  one  inch  from  the  external  opening.  The  membranes 
ruptured   during  the  examination. 

During  the  pains  that  now  came  I  executed  frictions  over  the 
sacral  nerves  and  also  in  the  lumbar  region,  where  the  patient 
complained  of  pain.  These  frictions  were  performed  with  one 
hand  while  the  other  simultaneously  executed  vibrations  on  the 
coronal  suture.  Patient  liked  these  manipulations  very  much, 
and  told  me  that  they  not  only  relieved  the  pain,  but  also  gave 
her  energy  and  helped  in  the  expulsion  of  the  foetus. 

At  10.15  p.m.  the  labia  separated  slightly  during  each  pain, 
and  the  foetal  scalp  began  to  appear.  At  10.20  p.m.  the  head 
was  born  ;  and  one  minute  later  the  rest  of  the  foetus.  While 
the  child  was  being  attended  to,  I  executed  frictions  over  the 
uterus.  At  intervals  I  also  executed  sacral  nerve  and  uterine 
frictions,  and  stomach  exercise.  Patient  liked  the  manipulations 
very  much  and  said  they  made  her  feel  very  comfortable. 

The  placenta  was  born  entire  at  11.45  p.m. ;  I  then  executed 
a  few  more  uterine  and  sacral  nerve  frictions  ;  the  uterus  was 
well  contracted,  and  I  left  patient  at  12.10  a.m.  on  May  12. 

May  12. — No  after  pains  at  all.  Treatment  twice  by  sacral 
nerve  and  uterine  frictions  and  stomach  exercise. 

May  13. — No  after  pains.  Everything  going  on  favourably. 
Treatment  twice  on  same  lines  as  before. 

May  14. — Treatment  once  as  before. 

May  15.  —  Patient  got  up  during  the  morning  and  was  up 
most  of  day.     Treatment  once. 

May  16. — Patient  up  and  moving  about  as  usual.  Treatment 
for  last  time. 

September,  1902. — Patient  quite  well. 


X 


2: 


-^  c3 


O      ce  p^ 


C    , —  0) 


^         t: 


br.  .2     ;^''  .2 


3     & 


r-5        H        CD 


t>>  : 


=a  >«  =«  „  =a ;-,  =a  =a  =^  "«=«"«           "«=« 

CD  cTo'ct  ^'c5  «o  od'o"  cm"^*":©"              co"o 

CDCOL—         t-         L—  t-QO  QOCOCO                     OO 

CN  <M  (N         CM         CM  (?1  <M  (M  (M  CN                     CT  CN 

o  g 

;  :  :  :  ;i|  ;  ;  ;  :  ;          ii 

cS^      .     . 

ii'o  B< 

— "«  S  S       .^ 

=s  s  s  .a 

;    :    :    :-ga£    :    :  S    '2                  :    : 

^X:  £  ^       a 

r^  r^  r^  r^            >^_ 

5  5  -S  ^        -^ 

sag  s    = 

....ooo         .  o       o 

:    :    :    :000    ;    :  o      fe                 ;    : 

:    :        ::::::::::  :    :    ;  So"           •    • 

~g               go  0(M         2      -     - 

1-1       .              -tDo'05           "^O       .'^     rj  J  rH       .^       -      '^rt- 

ooot^i.-j;-j;t.te  cS   S,„   „            CM  ^• 

m  >-l         '-'  IM  CM  CM  ^/3  J  ^  Jd  ,a  ^^^^               «>  « 

S  i-s    i-sii(  [i!  P^S  B  S  S  S  S  §  S  <; -<        ■«:  <! 

—  CO  bo_ 

:'«§:::;::::::  :::::::  a^ 

■  3  S ?  3 

t,^    s-  S   ° 

: >  K  >  S  .    .    .    ."o 

^ea^;>    ^--^;-;-  ;:::■    •        I'^-bo 

3   CD  3  ■"  o:                    cc  •§, 

o  ^  'o  Q  ,^               ^  o 

E-1      EhcO  g               ,=5 


ce  ,-H 


CO  CM         C7DlOOiOC::(X)ScMOCC 
CO^  cmrHCOrH  CM^  "-^^ 

;2 


ggS       f^^f^f^f^f^^f^'S^       feg  BnliiSfiiS^ 


d  <:  1-i     g  -5  ffi  S  C  K  S  a?  H  H      cc  <?" "  g  S  g>ffi  K 


liOCOt-CCOOt-HCMCO         Ti(»OCOt-GOOSO» 


• 

o* 

y- 

^ 

U 

y 

«« 

M 

00 

IJij 

Ol    CO 

^ 

<« 

ii 

oT 

oT 

g 

^- 

00  en 
.1^   en 

o 

o" 

oT 

05 

o 

(M 

(M 

Ol 

CO 

CO 

CO 

3 

M 

cf 

*3 

1 

g 

a 

3 

t3 

•3 

l-s 

a 

1 

^ 

f 

^ 

cc 

CC 

a 

-o 

o 

^ 

a 

3 

'rt 

iS 

p. 

g 

a 

2 
0. 

fl 

'^ 

S 

a 

"  o 

a^ 

.2 

3 

ca 

eS 

a 
ea 

a 

a 

■§ 

3 

|i( 

a 

ca 

tK  lO  o 

:S 

S 

a 

S3 

a 

a    - 

0 

" 

§ 

1 

a 

ja 

IB 

s 

> 

^ 
» 

1 

i 

J3 

O 

cd 

ca 

Si 

ice 

-a 

ca 

i 

P3 

§ 

a 
3    : 

^ 

>>            :    : 

:  >>>^ 

>i 

>.rt 

;   >i 

>> 

>> 

t^             :    : 

m 

CI    ^ 

^ 

0 

>    ^   . 

> 

> 

§1   = 

^ 

> 

> 

„ 

„ 

.  t- 

;> 

„ 

-   . 

O 

-  *  ' 

' 

" 

' 

o 

a 

o 

"" 

' 

"8 

0 

' 

"   ' 

^ 

^ 

^ 

d^ 

2 

2 

:   2 

g 

^ 

'  _^ 

^ 

^ 

J 

_^ 

„ 

^ 

^ 

«£    -  - 

*2 

*2 

"■  ^ 

-   -   - 

^ 

, 

-« 

•*i 

d 

-a  ,2 

r 

r 

-U3 

*£ 

- 

*   ' 

(£          i 

■cSal 

(S 

^•2    S 

5 
di 

(S 

T-i              ■ ' 

!3.^  <    :    : 

1 
o" 

■  i- 

°  of 

1    •§ 

5is 

o" 

00 

oo" 

Ol 

g 

T-I 

a' 

iii 

i 

CO 

fo 

C!  oo"    . 

g  0^1  Ol 

1 

0 

si 

g   1  -a    .    . 

7 

1= 
11 

Q  S< 
1         1 

a, 

CO 
] 

2P 

1 

3 
-1^ 

1 

1    1  1 

"3 

1-5 

1 

"3 

<;'3 
1    '7 

1 

j' 

fe 

i 

a  i 
1    1 

ec  g:  cc     •    ■ 

;  "^ 

G^ 

sss 

t- 

00 

^ 

■"^^ 

oq  on  "^ 

1 
CO 

l-s 

si 

10" 

1 

CO 

t-  Oi 

"o^ 

1 

CO 

5  -^  = 

O     Q,   O 

ca 

P, 

'C  bb 

^  obti 

bb 

00 

bb 

u 

>    bb'^S^ 

>.^ 

bb 

J3 

"S' 

s  >■ 

J3    S'JS      .      . 

eg 

a  p 

O    3    3 

3 

3 

3 

°    3   aJ 

3 

■3    3 

3 

55 

<lC<    :    : 

S 

0-<C<!-^ 

«: 

< 

< 

G 

!?  <C0 

s 

1-3  l-a  Ha 

<! 

fe 

(S 

i-»a 

o 

2 
■ft 

-a 

a 

^ 

a 

a 
3 

1 
3    ■ 

'    '  S    '    ' 

■J 

.     .     ' 

-5 

.3 

> 

s 

'C 

'■§ 

\3    'i 

ea 

3 
O 

■  bo 

s 

bb  o 

3.2 

ca 

a 

2  ■" 

o. 

a 
3 

a 
ca 

2! 
^^ 

2"^ 

11 

Measles 

German 
Mumps 

:  : 

: 

'5, 
-  o 

3 

a 
I— t 

= 

1 

■ft, 

sl 

ta  a  d 

a^  a 

-3  Si -a 

'     - 

ca  0 

S.S. 
3  3 

<< 

ja 

^ 

in       o        S 

*"o 

Ol 

O  -H 

-*    O  "^ 

o 

00 

lO 

o  >o  oi 

00 

coco  lO 

0 

L_ 

Ttl 

rH  0 

"  ■*  -■      g 

"-^ 

g<M 

<M 

CM 

i-H            .^ 

Ol 

Ol 

r-l  CO 

(TO 

-*J 

t- 

o 

pi^  [^  ^  I^'  s 

f^'S 

s 

ggp^'p^isp^; 

S 

S 

^ 

P=        fefe 

s 

Iii 

SS 

fR 

fe 

S 

SS 

g 

a 

X 

y. 

. '? 

<d 

.2 

.2 

hi^Ii^ 

l-=  <i1  ^  CLi'  M 

H 

cc 

d 

u}--6^ 

1 

Wf^ 

«■ 

cc 

-<il4 

<1  ja 

"ccd 

o"K 

<K<! 

g 

e4 

&^' 

oo 

•^*  ^fi 

3 

bo 

■a 
3 

-<■<; 

W 

^ 

dt^' 

S 

n3 

T3 

a 

CMC0-*OOt-C0O 

o  ^ 

>o 

CO 

^ 

00 

O    O  -H 

oq 

CO 

T«  « 

CO 

~ 

CO 

0  0 

OJGqO)C>4G<I<McqcM 

CO  03  CO  CO  CO 

CO 

CO 

CO 

CO 

CO  -#  -^n 

■^ 

Tfl-cd  tH 

-># 

1*  »Q 

ill 

335,  Ac. 

345,  &c. 

346,  &a. 

336,  &o. 

339,  &c. 

341,  &c. 
482 
483 

316,  &c. 

a 

5 

■«._.........        ::        ::        :        :;: 

s 

i                                                          ::::::::                                        : 

•z  '''--''-''  '     :  :      :  :      :      \  ■  ':                        ■. 

1 

£ ^^^.       r:       :       :'a'a^^^,2        -.2;:^-- 

S g^S    -                            .2.2  S  £  >>S        'S^£   "  ' 

P-i                                              CU      Pj                                     QQPjPl,-")!,           Pj      PL, 

1 
s 

■•■••■■■•  -1  ■    -  ■    '■  '    ■    ^  '  ^  ^  ^    ''    ''  ''    •  •  ^ 

flii^all^lii  M  II 1  mil  f  1^  III 

"o,  =3  ^  t>  >'  ^  >'  >  ^  >  u  't^      -13  o       bb  si     ^     ^  'S  aJb  ab  ^     "C       d  "      r^'  ^JS 

Name  of  Disease 

::::::::::::         ^  §      -g  g       g         ^    ^    =.2     ^       g.        =    ^         "    ^    ^ 

m       S  p,      cu                    c           JS                            -3 

::::::.         r-Sg'^'^                    J-                  ::               3 

.2 -2     •^'3     "3     -J         'i    '      >       '    '     -J      § 

1                     i^|i  j;i    ti  1   ■  •  1  1 

(B                                                                 a  H  a>  <D'S  a'S  <B             <d'5o.2&Ph(ii'* 

< 

to 

1 

feNSSS'feSSfe'lilSS       Sfe       li^g       S       Pq'fegfaP:;       fe       ^^       fe  ii;  si 

1^1 

j5 

y- 

^■ 

QoS 

cri" 

=a 

i 

s 

CO 

CO 

X 

CO 

CO 

*= 

;:; 

f^  « 

.. 

0  tS 

U} 

5 

*  »n 

uo 

0 

d 

CJ 

>; 

p4 

3 

C3S 

"« 

^ 

:^ 

3 

cr' 

>^ 

s 

iH 

3  => 

"S 

> 

B 

5 

o-^ 

■g 

a 
0 

3 

3 
3 

1 

3 

0  J 
■^  0 

og-l 

I 

d 

0 

ll 

"3 

0 

1    ' 

&  >,     "§ 

3 

3 

0 

"c 

3  ^ 

^!=.3 

0 

0 

M 

Si  \ 

>1 

■    >^ 

^ 

:    :  C 

> 

. 

. 

„ 

.. 

>■    . 

-.   -   « 

-    -    - 

^ 

_ 

. 

^ 

§ 

" 

0    * 

"   '   ' 

'   '   ' 

" 

* 

" 

' 

h 

;    :  " 

_^ 

^ 

•S 

. 

. 

. 

. 

'g'^'S    : 

cu 

5q(£ 

1 

i 

CO 

i 

00 

to 

i 

of 

Cl 

(J,  ^cn        cq 

■-1         00 

0 
0 

i 

1 

i 

& 

tH 

^ 

tH 

2 
d 

g 

0" 

co"'"'  S  "^ 

C-flM      . 

^-   .^ 

-n" 

CO 

co" 

2 

"3 

1 

P< 

-13 

0 

t.t-^ 

S  a    . 

bo       &t 

rg 

> 

ji 

1 

00 

1 

0  AO^  Or/!, 

3         -< 

1 

1 

0 

1 

i 

»H 

'^ 

Ol 

J 

01 

CO  m°  -H 

"^  rt  oi 

S"     — 

^ 

0 

rH 

" 

"3 

1-3 

60 

3 

3 

»=H 

^ 

g'  00  >>  :>■  >  ^  -" 

t2  3  '3       ^       S 

f^  ■<  H3  ^  ^  <5  f-» 

'3        *C 

< 

S5 

^ 

0 
fe 

=1 

3 

3 

3 

3 

^1"^ 

''■  i  a 

0 

g 

0 

i§ 

s 

3 

s  § 

□ 

3 

3 

3 

i-  ^ 

S  0 

i» 

0  « 

0 

P< 

P< 

a 

o< 

& 

.2 

3^ 

«  0 

0 

'^ 

0 

"  "0 

" 

Q 

^  '0 

3 

3 
P. 

3 
P. 

3 
P< 

& 

0 
3 

>> 

0 

^^  3 

n  =  '"  •» 

-a 

n3 

3 

p. 

-a 

3 
C3 

C 
T3 

-c  p. 

3 

3 

3 

3 

3 

3 

1   ° 
3 

o^>,S  3 
^^  ^  3  =5 

3 

3 

c3 

3 

60 

S3 

60  bo 

■50 

3 

C3 

|3 

'■3  3 
60  a: 
5  -3 

3 

1^ 

a1 

3I 

h 

a  g 

i 

J 

^3      * 

cu  p, 
:3| 

H-o  3  J 

a 

a 

aofi 

_3 
60  g' 

a  a 

3 

a 

aog'i  60 

■< 

<; 

■< 

<! 

<; 

m 

< 

<s, 

<!<!h1 

^J 

■A 

ij 

^ 

1 

J3 

■* 

lO 

CO 

CO    g  10  0  10  CN  00 

CO   3  CO 

cr; 

en 

CO 

^ 

t- 

w   0^ 

01 

S 

s 

fe 

S 

B 

S  fe  fe'  ^ 

g  lii  P^' 

B^'&i 

S 

b 

s 

B 

X 

.2 

«■ 

aj 

aj 

i4 

■< 

h-; 

5^  J  d  S 

c/i'^<j 

-a    .    . 

<:' 

j_j 

<;' 

cc 

Ph' 

a 

W 

1=^ 

< 

d 

^'  e4  k  k 

aJ 

< 

Q 

^' 

s 

Cl 

o 

^ 

(M 

m 

^ 

10  0  t-  00  en  0  rH 

C<l  CO  « 

10 

CO 

c- 

05 

t' 

CO 

CO 

CO 

00 

00 

0  CI  c:5 

01 

CI 

31 


482  APPENDIX 

I  shall  now  proceed  to  fjive  a  few  brief  notes  of  the  cases  in 
the  above  list  in  which  death  resulted. 

Case  2  (A.  F.). — TijpJioid fever. — Patient  had  been  suffering 
from  the  above  complaint  since  May  2,  1902.  I  was  called  in  on 
May  9.  For  the  past  six  days  patient  had  had  an  evening 
temperature  of  from  103'7°  to  105-1°,  with  morning  remission 
of  only  one  to  two-fifths  degree.  Examination  :  Patient  very 
weak ;  semi-unconscious ;  great  distension  of  the  abdomen ;  olive- 
green  motions  ;  cardiac  action  irregular.  May  10,  cerebral  symp- 
toms set  in,  delirium  at  intervals  with  muscular  twitchings ; 
cardiac  action  intermittent.  May  11,  threatening  heart  failure 
all  day,  great  irregularity  and  intermittence.  During  the  evening 
violent  delirium  for  nearly  four  hours  without  intermission.  May 
12,  meteorism  more  marked ;  heart  slightly  better  than  during 
the  previous  day.  During  the  evening  some  delirium  for  an 
hour,  after  which  collapse,  coma  vigil  and  death  at  6  a.m.  on 
May  13.  From  May  10  to  13  the  temperature  fluctuated  between 
102-4°  to  103-7°,  and  pulse  between  132  and  144. 

Case  39  (J.  S.). — Diphtheria. — Patient  had  been  suffering 
from  the  above  complaint  for  ten  days  before  I  was  called 
in  (November  27,  1899).  Examination:  Patient  already  had 
complete  laryngeal  paralysis  and  evidence  of  the  diphtheritic 
membrane  in  the  bronchi.  Temperature  lOl'G",  pulse  120. 
November  28,  dyspnoea  and  violent  paroxysms  of  coughing, 
during  one  of  which  a  cylindrical  piece  of  membrane  one  and  a 
half  inches  long  and  one-third  of  an  inch  thick  was  coughed  up. 
November  29,  condition  about  the  same,  -05  per  cent,  albumen. 
November  30,  membrane  extending  down  into  the  smaller  tubes. 
December  1,  cyanosis  marked,  heart  irregular.  December  2, 
patient  very  weak,  great  cardiac  dilatation.  December  3,  con- 
vulsion shortly  after  midnight,  after  which  patient  became  semi- 
unconscious  and  died  at  about  (5  a.m. 

Case  (39  (Mrs.  L.). — Acute  peritonitis. — Patient  had  been 
suffering  from  this  complaint  since  April  11,  1900,  and  had  been 
heavily  dosed  with  the  Swedish  tincture  thebaica.  On  April  16 
her  medical  man  stated  that  she  could  not  possibly  live  more 
than  twenty-four  hours.  Twenty  hours  after  this  opinion  had 
been  given  I  was  called  in  (April  17).  Patient  in  extremis:  great 
distension  of  abdomen,  cardiac  action  rapid  and  hardly  per- 
ceptible, retention  of  urine  for  the  last  three  days  necessitating 


APPENDIX  483 

the  use  of  a  catheter.  Temperature  104',  pulse  125.  Patient 
slightly  better  after  treatment.  I  treated  her  again  during  the 
evening  and  some  further  improvement  took  place.  I  said  that  I 
would  stop  overnight  in  the  house,  and  that  I  was  to  be  called  if 
she  became  worse.  At  2  a.m.  on  April  18  patient  did  get  worse, 
but  her  relatives,  who  had  peculiar  religious  ideas,  decided  that 
it  was  the  will  of  God  that  she  should  die,  and  that  I  should 
not  interfere.  I  accordingly  was  not  sent  for,  and  patient  died 
at  3  a.m. 

Cask  70  (J.  P.).  —  Acute  peritonitis.  — •  Patient  had  been 
suffering  from  the  above  complaint  for  twelve  days.  His 
medical  man  had  prescribed  him  the  Swedish  tincture  thebaica, 
and  on  August  2-5,  1900,  he  told  the  parents  that  there  was  no 
hope  ;  I  was,  however,  called  in.  I  found  patient  in  extremis, 
cold  and  clammy,  semi-unconscious,  with  great  distension  of  the 
abdomen.  Temperature  104'4°,  pulse  172,  very  weak.  I  treated 
him  three  times  during  the  course  of  the  day  without,  however, 
effecting  any  improvement,  and  he  died  at  midnight. 

Case  8-5  (W.  W.). — Broncho-pneumonia. — Patient,  who  was 
rickety,  was  seized  with  a  severe  attack  of  the  above  complaint 
on  April  16,  1900,  and  remained  in  practically  the  same  state 
until  May  8,  when  I  was  called  in.  No  advice  had  been  sought 
previously.  On  examination  all  the  signs  of  severe  broncho- 
pneumonia were  present ;  there  was  retraction  of  the  head. 
Temperature  104°,  pulse  160.  During  the  following  day  patient 
was  worse.  Temperature  104'4°,  pulse  180.  On  May  10  and  11 
patient  was  slightly  better,  on  May  12  worse  and  semi-uncon- 
scious.    Pulse  over  190.     Death  took  place  on  May  13. 

Case  86  (E.  L.). — Broncho-pjieumonia. — Patient  was  born 
prematurely  (seventh  month),  had  always  been  very  weak,  and 
had  hardly  grown  at  all  since  birth.  She  had  suffered  from 
whooping-cough  during  the  last  month,  and  on  August  24,  1902, 
broncho-pneumonia  set  in,  the  temperature  going  up  to  102-6'. 
She  became  steadily  worse  until  August  30,  when  her  medical 
man  pronounced  the  case  hopeless,  and  I  was  called  in.  Exam- 
ination :  Patient  very  ill ;  marked  cyanosis ;  semi-unconscious- 
ness ;  signs  of  severe  broncho-pneumonia.  Temperature  104°, 
respiration  60,  pulse  16-5.  August  31,  condition  still  worse. 
September  1,  still  worse  ;  patient  looked  as  if  she  might  die  at 
any  minute.     September  2,  death  at  2  a.m. 


INDEX    OF    NAMES. 


PAGE 

PAGE 

Asp 

..      156 

Efron          154 

Atterbom  . . 

3 

Eickhoff 154 

Axenfeld    . . 

..      144 

Engstrand              . .              347,  348,  424 
Eulenburg,  M.  12,  38.  50,  145,  322,  355 

Baynud    . . 

..        47 

Beck 

..      154 

Foster      . .          . .          . .          .  .        29 

Berghmann 

..     210 

V.  Frey       . .          . .          . .          .  .        47 

Bernard,  CI. 

29 

Friedrich   . .          . .          . .          .  .      322 

Beskow 

3 

Frost          3 

de  Betou    . . 

..      145 

Blundell     .  . 

145,  311 

Gartner    . .          . .           . .          . .      322 

Bock 

..      145 

Gaskell 29 

Boruttau   .  . 

..      144 

Gasne          . .           .  .           .  .           .  .        84 

Brandt,  Th.        4,  96,  182 

,204 

,  234.  243 

Genersich 32,  38 

Branting    3,  4,  6,  9,  12, 

14,  16,  42,  49, 

Georgii    3,  4,  6.  9,  10,  12.  33,  38,  47. 

50,  145,   146, 

160, 

173.   181, 

49,  83,  122,  123,  144,  145,  160. 

183,  184,  211. 

213, 

223,  224, 

173,  181,  183,  191,  201,  204. 

234,  243,  251, 

311 

322,  323, 

211,  213,  224,  237,  243.  251. 

355 

311,  3'2-2,  355,  463 

Braune   30,  31,  48,  59,  C 

4,  65,  83,  104, 

Gerst          223 

125 

Glatter 

146,  147,  311 

Broadbent 

..      460 

Goltz 

229 

Broman 

.  Preface,  124 

Gotch 

.  .      155 

Brunton  and  Tunnicliffe 

29 

Granville   . . 

..      182 

Bum 

. .      212 

Gray 
Gubler 

89 
.  .      200 

Campbell  . . 

29 

Gustaf son . . 

..      312 

Cathcart     . . 

89 

Charon 

32 

Hamz 

29 

Chipault    . . 

84 

Hallst^n     . . 

..154 

Cleland       . . 

89 

Hartelius     4,  5,  7,  9,  10,  12,  33,  38.  49. 

Cleland  and  Mackay 

89 

50,   67,   88,    127,    146,    169. 

Curman 

..      211 

181,  182,  183,  185,211,213, 

Cyriax,    Annjuta . . 

Preface 

243,  318,  323,  333,  335,  345, 

Cyriax,  Edgar 

..     393 

355 

Cyriax,  Eva 

Preface 

Hasebroek 
Hasse 

29,  182,  312,  357 
. .      125 

Dalla  Rosa 

89 

Haycraft   . . 

28 

Dolega 

. .      312 

Head 

165 

Dolgiel 

.  .      126 

Hegar 

84 

Dollinger   . . 

..      312 

Heilemann 

29 

Bonders     .  . 

..      224 

Heitler 

2(i:i 

Dybkowski 

84,  126 

Hellberg     .. 

448 

Helleday    . . 

182,210 

Edgecombe 

32 

Henke 

98 

Edkins 

..      153 

Herzog 

30,  48 

INDEX    OF   NAMES 


485 


PAGE 

PAGE 

Hill              ..           ..               152 

200,  229 

Mosso 

29 

Hill  and  Nabarro .  . 

30 

Miinchenberg 

. .      355 

Hill,  Baynard  and  Sequeira 

47 

Munk 

150,  203 

Hoffa     " 

198,  212 

Munk  and  Sehultz 

.  .      154 

Hultkranz 

..      101 

Murray     . . 

5,  6 

182,  191,  243,  466 

Hum'lewski 

29 

Hiinert'autli 

..      312 

Nbbel 

182,  312 

Hunt           

152,  156 

Neumann,  A.  C 

4, 

10,  11,  29,  38,  46, 

50, 

84, 

22,   145,   146,   181, 

In  de  Betou.     See  Betou. 

183, 

184, 

210,  213,  224,  225, 

234 

247, 

249,  311,  318,  322, 

Kaufmann  . . 

29,  30 

355 

Kellgren,  Arvid        9,  133,  147, 

151,  182, 

Nussbaum 

..147 

312 

Nyblseus     . . 

3 

Kellgren,  Harry         Preface,    288,    331, 

Nycander  . . 

. .      323 

378,  403, 

433,  458 

Kleen          .  .           .  .               152, 

212,  312 

Oebtel 

. .      358 

V.  Kries 

47 

Oliver 
Owen 

29,  30,  32,  125 
.  .      460 

Langesdorff 

..      144 

Lassar 

39 

Paschutin.  . 

32,  38 

Lavalette  .  . 

..      141 

Petersen    . . 

67 

Lesser 

32,  38 

Levertin    .  . 

..      182 

Ranke 

30 

Levin          ..     5,  147,  182,  192, 

243,  335 

Ranvier 

29 

Liedbeck,  C.  H 

182,  243 

V.  Recklinghausen 

. .      126 

Liedbeck,  J. 

3 

Reibmayr 

139 

141,  142,  212,  312 

Liedbeck,  P.  J 

..      213 

Reid  and  Sherrington      . .            84,  122 

Liljevr.lch  .  . 

..      204 

Richter      .  . 

38,  247,  322,  355 

Ling,  Hj.     4.  6,  12,  30,  33,  34,  38,  46, 

Riecke 

.  .      322 

49,   50,   60,   63,   71 

72,  78, 

Roth     12,  145, 

181, 

183,  184,  210,  213, 

82,  83,  84,  90,  141, 

145,  155, 

355 

156,  160,  183,213, 

219,  224, 

Rothstein    3,  4 

,   12, 

29,   38,   145,   181, 

229,  243,  247,  311, 

318,  355 

183, 

210, 

213,  322,  355 

Ling,  P.  H.    1,  2,  3,  6,   16,  29 

,  31,  33, 

76,   83,  84,   144, 

155,  164, 

Sadler 

29,  30 

180,  182,  210,  ;: 

13,   223, 

Sadolin       . . 

15 

224,    234,   243.    247,    251, 

Saquet 

..141 

355 

Satherberg 

321,322 

Lorand 

..      191 

Schiifer 

..144 

Loven         38,  83,  125 

Schott 

. .      359 

Ludwig  and  Schweigger  Seidel 

Schreber    . . 

..311 

28 

,  39.  126 

Sehultz 

..154 

Scliweigger-Seidel 

28,  29,  12.5,  126 

Mackay 

89 

Sczelkow    .  . 

29 

Malassez    . . 

32 

Sequiera    .  . 

47 

Marey 

47 

Sherrington 

.  .     39,  84,  122 

^Massnmnn 

6,  355 

Silow 

14 

Melicher       224,  225,  234,  318 

322,  355 

Sommerbrodt 

33 

Metzer 

210,  211 

Sonden 

29,  144 

Meuli 

47 

Spaltholz   .  . 

29 

Mitchell 

32 

Spehl 

30 

Miiller,  Axel     298,   350,  380, 

422,  424, 

Starling 

..    Preface,  32 

426,   445,   447, 

450,   454, 

Steinhausen 

89 

455,  407,  470,  4 

71 

Stendel 

. .      322 

llollier 

89 

Stintzing    . . 

28 

486 


INDEX    OF   NAMES 


PAGE 

PAGE 

Svahnbei'g 

Preface 

Weber 

322 

Thomson,  St.  Claiu 

..      186 

Weiss 

154 

Tigerstedt...           '28.152 

154, 

150,  159 

Weman 

182 

Tokaroff 

..      139 

Werhauff 

3 

Tomgren    . . 

..      3,  6 

Weyrich 

211 

Tourette  et  Chipault 

84 

Wide.  A. 

4,   7,   8,   9.    15,    16,   43,   50. 

Tourette  et  Gasne 

84 

97,  98,  109,  136.  147,  148, 

Tunnicliffe 

29 

182,  185,  200,  202,  211,  231, 
250.  251,  321,  333,  335.  346 

Uexkull  . . 

144, 

155,  156 

Wide,  O. 

8 

Ulricb,  S.  A. 

. .      322 

Wintemitz 

32 

Urlich 

47 

Wolff 

47 

ViEKORDT   .  . 

..     203 

Wretlind 
Wiindt 

146.147,311 
153 

Waller     . . 

..      159 

Wallgren    . . 

..      182 

Zander 

■   182,  243 

IXDEX     OF     SUBJECTS. 


PAGE 

Abdomen,  effect  of  activity  of  abdominal  muscles  on  tlie 

61 

„                 „        leg  movements  on  the 

59 

„                  „        triuik  movements  on  the    .  . 

78,  83,  85 

„           hacking  on  the 

201 

„           kneading  of  the.     See  stomach  exercise. 

„           shaking  of  the 

192 

„           vibration  of  the 

192 

"  Abdominal  massage  "    .  . 

230 

Abdominal  muscles,  reflex  contraction  of  the    .  . 

163,  230,  231 

,,           organs.     See  individual  organs  and  abdomen. 

Abscess  in  the  antrum  of  Highmore 

469 

,,           ,.       mammary  gland,  threatening    . . 

476 

middle  ear 

276,  478,  481 

Abscesses,  vibrations  around 

193 

Abduction  and  adduction  of  the  fingers 

93 

,.             „             „              .,       hip-joint 

93,  94 

„             „             „              ,,       knees  .  . 

95 

„             „              „       shovilder-joint 

. .       89-93,  241 

„             .,              „              „            „      mechanism  c 

f            . .           . .        89 

,.             „             ,.              „       thumb 

93 

Abortion     . . 

237 

Active  movements,  conditions  necessary  for     .  . 

U 

definition  of 

10 

effects  of 

27-38 

„            varieties  of  . . 

..       11,12,13 

Adduction.     See  abduction. 

.'Esthetic  gymnastics 

3 

Alternate,  definition  of     .  . 

42 

foot  flexion  and  extension 

71 

„          rotation 

99 

Amyotrophic  lateral  sclerosis     . . 

396 

Anacrotism  of  the  pulse  .  . 

47 

Anal  canal,  vibration  of   . . 

233 

„     htting 

233 

Ankle-joint.     See  foot  and  tarsal- joints. 

Antrum  of  Highmore,  abscess  -n  the 

469 

Anus,  frictions  and  vibrations  of 

233 

Apoplexy,     ^'ee  embolism  and  haemorrhage. 

Appendicitis,  acute  catarrhal 

335-341,  480 

,,             chronic 

347 

Appendix  vibration 

232 

Arching,  back 

80 

Arm,  abduction  and  adduction  of 

. .      89-93,  241 

„      bending  and  stretching 

53,91 

„      carrying 

117 

„      circling 

.  .     104,  105,  106,  130 

4SS 


INDEX   OF   SUBJECTS 


Arm,  clapping 

„     exercise 

„     flying 

,,      hacking 

„      raising  forwards  and  upward; 

„      rolling 

,,      rotation 

,,      stretching  outwards 

„  ,,  upwards 

„      swinging 

.,     traction 

„      vibration 
Arteries,  compression  of. 
Assistance,  movements  witl 
Axillary  vein 
Azygos  veins 

Babinsky's  sign    .  . 

Back  arching 

exercise 

,,      hacking 

raising 

Beating,  effects  of .  . 

modus  operandi 
,,         on  muscles 
,.  ,,   oedematous  are; 

,,  ,,  the  sacrum 

over  the  spine 
Bending  an-.'  stretching      See  flexion  and  extension. 
,,         forwards 
,.         knee 
,,         sideways 
Biparietal  movement 
Bitemporal  movement 
Bladder,  incontinence  of 
,.         shaking  over 

sympathetic  ner\'es  of 
Blood,  diseases  of  the 

„       effect  of  dviplicate  movements  on 
,,  .,       passive  movements  at  joints  on 

,,       supply  to  active  and  resting  muscles 
,.       vessels,  effect  of  compression  of 
„  ,,  ,,        duplicate  movements 

„  „  „        nerve  frictions  on 

,,  ,,  ,,        passive    movements  at  joints 

,,  „  ,,        traction  on 

Body.     See  trunk. 
Brachial  plexus  paralysis 
Brain,  embolism  of 
,,       haemorrhage  into 
,,       hypersemia  of 

See  individual  diseases, 
Branting's  digitalis 
Breathing.     See  respiration  and  respiratory  exercises. 
Bronchi,  nerves  of 


PAGE 

203 
225 
103 
201 
40 

103- urn 

!)7 

53 

53 

49 

114,  115 

18<l 

213 

13,  393 

48 

85,  100 

..  151 
80 
.  .  239 
..  200 
79,  80 
.  .  199 
197,  198 
.  .  204 
..  204 
.  .  203 
.  .   204 

200,  201 
66 
84 
..  217 
.  .  218 
..  474 
168,  109,  233 
165,  168 
.  .  380 
31,  32 
31,  38 
30 
..  213 
28-31,  35 
150,  152,  162 
38,  39 
28 

..  396 
396,  397 
396,  397 
396,  450 

..   191 


INDEX   OF   SUBJECTS 


Bronchitis,  acute  . . 

,,  chronic 

Broncho-pneumonia 
Bulbar  paralysis     . . 

Calf  muscle  stretching    .  . 
Carpal-joints,  flexion  and  extension  of   .  . 
„       radial  flexion  of     .  . 
,,            ,,       rolling  of    .  . 
,,            ,,       rotation  of 
,,            ,,       ulnar  flexion  of      .  . 
Carrying,  arm 
„          elbow- 
leg  

Catarrh.     See  individual  diseases. 
Central  Gymnastic  Institute 
Centrifugal  kneading.     See  kneading. 

,,  stroking.     iSee  stroking. 

Centripetal  kneading.     See  kneading. 

,,  stroking.     See  stroking. 

Cerebral  disease.     See  brain  and  individual  diseases. 
Cerebro-spinal  fluid 

.,  meningitis,  epidemic 

sclerosis.     See  disseminated. 
,,  system,  effect  of  duplicate  movements  on 

,,  „  ,,        nerve  frictions  on 

,,  ,,  ,,       passive  movements  at  joints  on 

,,  ,,  ,,        stomach  exercise  on    .  . 

„  „        traction  on 

See  nerves. 
Chest  clapping 
,,      expansion     .  . 
,,      lifting 

.See  also  lungs,  respiration,  thorax. 
Chlorosis 
Chorea 
Circling,  arm 

Circulation.     .See  blood,  blood-vessels,  lymph,  respiration. 
Circumduction  (rolling)  of  the  fingers     .  . 
,,  ,,  ,,       foot 

,,  ,,  ,,      head 

„  ,,  ,,       hip-joint 

,,  ,,  .,       shoulder-joint   .  . 

„  „  „       thumb     .  . 

,,  ,,  ,,       toes 

„  „  „      trunk 

,,  ,,  ,,       wrist-joint 

Clapping,  effects  of 

,,  modus  operandi 

„  on  the  chest 

,,  ,,       extremities 

,,  ,,       soles  of  the  feet 

Classification  of  movements 

,,  positions 

"  Cold  shivers  '*  sensation 


489 
PAGE 

1G4,  168,  316,  480 
164,  168,  435,  437 
481,  483 
396,  420 

..  215 
56 
56 

..  106 
97 
56 

..      117 

..  118 
61 


186.  41!) 
298,  479 

32,  33 

150,  &c. 

39 

.  .      230 

28 

.  .  202 
124-130 
..      127 

..  380 
..      396 

104,  105.  106,  130 

..      106 

..      109 

..      110 

..      107 

103-106,  130 

.  .      106 

..      110 

110 

..      106 

..      199 

197,  198 

.  .      202 

.  .      203 

.  .      203 

10.  11,  41 

14.  &c. 

160,  166,  173 


49"  INDEX   OF   SUBJECTS 


Compression  of  blood-\'essels  and  nerves.     >S'ee  pressings. 

,,               spinal  cord  from  scolio.sis           . .  .  .  . .  . .           . .      39(> 

Concentric  movements.     See  duplicate  movements. 

Concussion  of  the  brain    .  .           .  .           .  .           .  .  .  .  .  .  .  .           .  .      39(> 

Constipation           ..           ..           ..           ..           ..  ..  ..  34!l,  350,  351 

Convulsive  tic        .  .           .  .           .  .           . .           .  .  . .  .  .  .  .           .  .      39(> 

Coordination  33,  03,  82,  203,  393 

Coronal  suture  vibration               169,180,238 

Corsets  for  spinal  curvatures        .  .           . .           . .  . .  . .  .  .           . .      333 

Coryza         . .           . .           . .           . .           . .           . .  . .  . .  . .           .  .      186 

Crises  in  locomotor  ataxia,  treatment  of             . .  . .  . .        •   . .  .  .      394 

Croup  48(.) 

Cutaneous  nerves.     See  nerves. 

Cutis  anserina        .  .          .  .          .  .          . .          . .  . .  .  .  . .          .  .      161 

Defokmitie.s,  general  principle  for  the  treatment  of  .  .  .  .  . .              75,  76 

Delirium  tremens  .  .           .  .           .  .           . .           . .  .  .  .  .  .  .           .  .      396 

Dementia,  syphilitic          .  .           .  .           .  .           . .  . .  . .  .  .           .  .      397 

Depletion.     See  depletive  and  head,  depletion  of. 

Depletive  exercises             ..           ..           ..           ..  ..  ..  ..               31,39 

Derivative  exercises           .  .           . .           .  .           . .  . .  . .  .  .              31,  39 

Derived  positions  .  .           . .           .  .           . .           . .  . .  .  .  .  .         14,  16-26 

Diagnosis  by  touch            .  .           .  .           .  .           . .  . .  .  .  .  .           .  .      248 

Diagnostic  exercises           . .           .  .           .  .           . .  . .  . .  . .     36,  37,  247 

Diaphragm,  nerves  of        .  .           .  .           . .           .  .  . .  . .  .  .           . .      165 

Diaphragmatic  pleurisy    .  .           .  .           .  .           .  .  . .  .  .  . .          165.  481 

,,               spasm       ..           ..           ..           ..  ..  ..  ..          KiO,  "217 

,,  suction.     See  subdiaphragmatic. 

Diarrhoea    .  .           .  .           .  .           .  .           .  .           . .  . .  . .  . .           .  .      353 

Dicrotism  of  pulse              ..           ..           ..           ..  ..  ..  ..           ..162 

Diet  for  cases  of  fever       .  .           .  .           . .           . .  . .  .  .  . .           .  .      252 

Digestive  organs,  diseases  of        . .           .  .           . .  .  .  . .  . .           • .      334 

Dilatation  of  heart.     See  heart  disease. 

Diphtheria 291,479,482 

paralysis  after             293,  396,  445 

Diplegia,  from  cerebral  ha?morrhage      . .           . .  . .  . .  .  .  396,  397,  407 

„         infantile  spastic              .  .           . .           .  .  . .  . .  . .          396,  403 

Dislocation  of  left  humerus           .  .           . .           . .  .  .  •  ■  •  .           .  .      472 

,,            of  right  humerus        .  .           . .           . .  .  .  .  ■  •  .           •  •      470 

Dispersing  vibrations        . .           .  .           . .           . .  . .  .  .  .  .           •  .      140 

Disseminated  cerebrospinal  sclerosis     ..  ..  ..  ..      161,221,396,423 

Dovible,  definition  of          .  .           .  .           . .           . .  . .  .  .  .  .           .  .        42 

Drawing  backwards           .  .           .  .           . .           . .  . .  . .  .  •           •  .      122 

,,         forwards..           ..           ..           ..           ..  ..  ..  ..           ..119 

„         sideways              ..          ..          ..          ..  ..  ..  ..          ..      121 

Ductless  glands,  diseases  of         .  .          . .          . .  .  .  .  .  .  •          . .      387 

Duplicate  movements,  advantages  of     . .           .  .  . .  . .  .  .           .  ■        36 

„                    ,,            definition  of         . .           .  .  . .  .  .  •  .           .  •        1 1 

„                    „            physiological  effects  of  .  .  . .  .  .  . .               27-38 

„                  „           varieties  of           . .          . .  . .  .  .  •  •          .  •        1 1 

E.\K  disease,  middle           ..           ..           ..           ..  ..  ■■  276,478,481 

Ear,  shakings  and  vibrations  on               . .           . .  .  -  . .  •  •           •  •      187 

Ear  exercise            .  .           .  .           . .           . .           . .  .  •  ■  ■  ■  •           •  •      225 

Effleurage 210 


INDEX   OF   SUBJECTS 


491 


Effusions,  hackings  and  beatings  over 

kneadings  of     .  . 
Einleit  ungsniassage 
Elbow  carrying 

,,       flexion  and  extension  of    . , 
,.  ,,         ,,  „  muscles  performing 

,.       pressing  backwards 
„  ,,         downwards  and  upwards 

Electrical  stimulation  of  nerve 

,,  ,,  ,,       ,,      differences  from  1 

Electricity  in  nervous  diseases     .  . 
Elimination  of  muscular  action  . . 
Elongation  of  spinal  cord 
Embolism  into  internal  capsule  . . 
Epidemic  cerebro-spinal  meningitis 

„  parotitis.     See  mumps 

Epididymis,  vibrations  on 
Epilepsy 

Epileptic  seizure  while  bathing  . . 
Epistaxis    . . 
Erysipelas  .  . 
Erythema  nodosum 

,,  rheumatic 

Eversion  and  inversion  of  the  foot 
Excentric  movements.     See  duplicate  movements 
Exercise.     See  movements. 

,,         arm 

,,         back 

,,         ear 

,,  eye 

,,         head 
leg 

,,         stomach 

,,         throat 
Exercises,  diagnostic 

,,  modifications  in 

Exophthalmic  goitre 
Expansion,  chest  . . 

See  also  respiration. 
Eye  exercise 
,,     vibration 

Face,  movements  of 

Facial  paralysis 

Fainting 

Falling  backwards 

,,       forwards    . . 
Femoral  vein 
Fever,  effect  of  nerve  frictions  on  cases 

,,       treatment  of 
Fingers,  abduction  and  adduction  of 

,,         flexion  and  extension  of 

,,        rolling  of 
Fixation  in  duplicate  movements 
See  elimination. 


U,  33, 


35,  43. 


PAGE 
•202,  204 
209,  210 
.  .      212 

..     lis 

49-50,  200,  201 
49-51 
..   118 
91 
155,  15(i 
155,  15C 
146,  395 
,  30,  350,  393 
84 
390,  397 
298,  479 

. .  233 
..   396 

..  457 
49,  180 
293,  479 
309,  479 
300,  479 
.  .   102 


. .  225 
.  .  239 
.  .  225 
. .  224 
220-223 
. .  226 
227-231 
. .  223 
.  30,  37,  247 
240,  241,  242 
188.  387 
124-130 

224 
.  .   185 

..   217 

396,  444 

102,213 

78 

52,  78 

58,  59,  64,  108 

153,  162 

251,  252,  253 

93 

. .  56,  57 

.  .   100 

37 


INDEX    OF   SUBJECTS 


PAGE 

Flexion  and  extension  of  ankle-joints     .. 

. .      69-72,  241 

„               „ 

elbow-joint 

49-50,  200,  201 

•,               .. 

„          „      mechanism  of    .  . 

. .  49-51 

„ 

fingers 

56,  57 

„               „ 

foot 

. .       69-72,  241 

„               „ 

forearm 

. .  49-56 

„           .,               „ 

head    .  . 

. .  72-76 

„               „ 

hip-joint 

57-08,  94 

„ 

interphalangeal-joints 

.  .  56,  57 

,,          „               „ 

knee-joint 

.  .  63-69 

„ 

raetacarpo-phalangeal  joints 

56 

,,          „              „ 

metatarso-phalangeal  joints 

74,  241 

..          „               ,> 

shoulder-joint 

4.5-49 

»           »               » 

„             „     mechanism  of 

45 

„          „               „ 

tarsal-joints    .  . 

.  .     69,  72,  241 

.,          J,               ,, 

thumb              

56 

,,          „               „ 

toes 

. .        72 

„          „               „ 

trunk   . . 

70-SS,  200,  201 

,,          „               ,, 

wrist-joint 

50 

,,           ,,               ,, 

lateral,  of  head 

75 

„         trimk 

. .  84-88 

Flying,  arm 

. .      103 

Foot,  clapping  on  the  soles  of       .  . 

.  .     200 

„      flexion  and  extension  of     .  . 

.  .       69-72,  241 

„      inversion  and  eversion  of  . . 

.  .      102 

„      rolling  of 

.  .      109 

Forearm  flexion  and  ex 

tension  {see  elbow-joint)   - 

.  .  49-50 

Friction,  pressure .  . 

.  .      142 

Friction  vibrations 

..143 

„                 „           with  suction .  . 

..143 

Frictions  on  abdominal 

organs.     See  indi\'idual  organs. 

,,  muscles 

194.  195 

„           „  nerves.     See  nerve  frictions. 

„           „  salivary  glands 

.  .      196 

„         round  ulcers 

..196 

Fronto-nasal  running  v 

bration  .  . 

186 

Fundamental  positions 

14 

G.iLL-BLADDER,  frictions  on 

,,  nerves  of 

,,  shakings  on 

,,  vibrations  on 

Ganglia,     iScc  sympathetic  and  nerve. 
Gastro-intestinal  catarrh,  acute 
Gastrocnemius  muscle,  sprain  of 
General  principles  in  the  application  of 
Genital  organs,  female,  nerves  of 
,,  „  ,,         treatment  for 

„  ,,        male,  treatment  for 

Genito-urinary  organs,  diseases  of 
German  measles     . . 
Glands,  secretory  effects  from  nerve  frictions 

<S€e  individual  glands. 
Glycogenic  function 


the  manual  treatment 


..  232 

..  164 

..  232 

. .  232 

34.5,  480 
.  .  400 
.  .  249 
..  165 
234-239 
. .  233 
..  474 
479 
150.  153 

35 


INDEX   OF   SUBJECTS 


493 


Goitre,  exophthalmic 

Great  lateral  sinus 

Gunshot  paralysis 

Gymnast,  position  of,  in  Sweden 

Gymnastic  Central  Institute 

Gymnastic  Director 

Gymnastics,  jesthetic 

„  medical 

„  military 

„  pedagogical 

Hacking,  effect  of 
length     . . 
modus  operandi 
on  the  abdomen 
,,       arm 
„        back 
over  effusions     . 
on  the  head 
over  the  heart   . 
,,        kidneys 
of  the  lateral  aspect  of  the  body 

„      leg 
over  the  liver     . . 
on  the  lumbar  region 
over  muscles 
of  the  posterior  surface  of  the  body 

,,      shoulders 
over  the  spleen 

„     subcutaneous  effusions 
side  length 
Haemorrhage  into  the  brain.     See  heinipl: 
,,  ,,       ,,    spinal  cord 

„  subdural 

Hand  flexion  and  extension 
„      rolling 

See  also  carpal-joints 
„      and  foot  nerve  frictions 
„      and  foot  traction     .  . 
,,      to  foot  nerve  frictions.     See  nerv 
Hanging 

,,         position  .  . 
Head,  depletion  of 
,,       exercise 

,,       flexion  and  extension  of    .  . 
,,       hacking  on 

,,  lateral  flexion  and  extension  of 
„  lifting  of  . . 
,,  rolling  of  . . 
„  rotation  of  .  . 
,,  shaking  of  . . 
,,       vibration  of 

,,       to  foot  nerve  frictions.     See  nerv 
Headache    .  . 
Heart,  clapping  over  the 


PAGE 

188,  387 
..      173 
161,  396,  46a 

3,  5 

5 

3 

2,  3,  5 


199 

■2m 

197 
■201 
201 
•200 
202 
202 
201 
201 
201 
201 
201 
•201 
202 
20O 
•200 
•201 
202 
'201 

396 

396,  407 

56 

106 

..      180 
115,  116 

.  .      129 
16 

8,  73,  132,  219 
2'20-^223 
7^2-76 
. .     •20^2 
75 
131,  184 
..      110 
8,  181,  184 
..      184 
..      184 

161,  221,  456 
. .      ^203 


494 


INDEX    OF  SUBJECTS 


Heart,  effect  of  duplicate  movements  on 
,,  ,,        leg  movements  on 

„  ,,        nerve  frictions  on 

„  ,,        respiration  on      .  . 

,,  ,,        spleen  frictions  on 

,,  .,        stomach  exercise  on 

.,       hacking  o%er 
.,       nerves  of     . . 
,,       shaking  of  .  . 
,,       vibration  of 
,,       diseases 
Heel  raising 
Hemiplegia 
Hernia 

Hip-joint,  abduction  and  adduction  of  . . 
,,  flexion  and  extension  of 

,,  ,,         ,,  .,  (if  the  tnmk  on 

„  rolling  of 

,,  rotation  of 

See  leg. 
Humerus,  dislocation  of   .  . 
Hydrocephalus 
Hyperfemia  of  the  brain  . . 

See  headache. 
Hysteria 


192, 
150, 


PAGE 

33,  34,  356,  357 

CO,  07 

159,  162 

124,  125 

.  .      358 

. .      229 

. .      201 

159,164 

.  .      190 

..191 

303,  355,  &c.,  399 

71 

151,  161,  396,  397 

82,  122 

93,  94 

57-68,  94 

77-80,  200,  201 

..107 

. .        97 

470,  472 
396,  403 
.  .      396 

. .      396 


Individualising  of  exercises 
Infantile  paralysis 
Infantile  spastic  diplegia 
Inferior  vena  cava 
Influenza     .  .  .  .       ■    . . 

.,  sequelae  of 

Inhibition,  sense  of 
Insomnia     . . 

Insular  sclerosis.     >S'ee  disseminated. 
Intra-abdominal  pressure.     See  abdomen. 
Internal  capsule,  embolism  into 
Internal  jugular  vein 

Interphalangeal-joints.     See  fingers  and  thumb 
Intertarsal-joints.     See  tarsal-joints. 
Intestinal  catarrh,  acute  . . 
,,  ,,        chronic 

Intestines,  effect  of  stomach  exercise  on 

,,  frictions  on      . . 

,,  nerves  of 

„  shaking  of 

„  vibration  of      .  . 

Inversion  and  eversion  of  the  foot 


43 

. .  396,  437-444 

396,  403 

83,  85,  100,  125 

.  .      479 

454,  455 

33,  393 

88 


396,  397 

48,  73,  74,  75,  132,  184,  213 


346,  480 

..  351 

..  229 

..  232 

..  165 

. .  232 

..  232 

..  102 


Jaundice   .  . 

Jaw,  lower,  movements  of 

upper,  shaking  and  vibration  of     . . 

Joints,  effect  of  duplicate  movements  on 

,,  ,,         passive  movements  on .  . 


..      480 

181,216 

..      186 

35 

39,  40 


INDEX  OF   SUBJECTS 


495 


Joints,  effect  of  traction  on 

„       kneading  of 

„       shakings  of 

,,       traction  of .  . 

„       vibration  of 
See  individual  joints. 
Jugular  vein,  internal 


Kellgren's  crossed  plantar  sign 

„  plantar  sign 

Kidneys,  effect  of  stomach  exercise  on 
,,         frictions  of 
,,         hackings  over 
,,         nerves  of 
„         shakings  of 
,,         vibrations  of 
See  nerves,  renal  plexus 
Kneading  of  abdomen. 
,,  ,,  effusions 

„  „  joints 

„  ,,  muscles 

,,  suprapubic 

Knee  abduction  and  adduction   . . 
linee  bending 

,,     pressing  down 
,,     raising 
ICnee-joint.  flexion  and  extension  of 
.,  rotation  of     .  . 

,,  synovitis  of    . . 

Jvneeling  position 

,,  ,,         positions  derived  from 


See  stomach  exercise. 


L.\BOUR,  treatment  during 

,,         case  of     .  . 
Laryngitis,  acute   .  . 
„  chronic 

Larynx,  nerves  of 

,,        shaking  and  vibration  of 
Lateral  flexion  and  extension  of  the  head 
,,  „  ,,  !,       trunk 

,,        sclerosis.     See  amyotrophic  and  paraplegia. 
Leg  abduction  and  adduction 
,,     carrying 
„    clapping 
,,    exercise 

„    flexion  and  extension 
,,    hacking 
,,    lifting  .  . 

,,  pressing  downwards. 
,,  raising. . 
,,  rolling 
,.  rotation 
„  swinging 
,,  traction 
,,    vibration 


PAGE 

•28 

•209,  210 

..      194 

28,  114,  194 

..      194 


48,  73,  74,  75,  132,  184,  213 


151 
151 
230 
232 
•201 
165 
232 
232 


•209,  210 

209,  210 

207-209 

234 

95 

60 

65 

05 

03-69 

98 

467 

15 


237 

476 
480 
467 
159 
188 
75 
84-88 

93,  94 

01 

203 

226 

68,  94 

•201 

94 

94 

02 

107 

97 

61 

115 

189 


496 


INDEX   OF  SUBJECTS 


phthisis,  respiration,  thorax. 


Length  hacking     . . 

Levers 

Lift  vibration 

Lifting,  anal  canal  and  anus 

„        chest 
Lifting,  head 

„        leg 

,,        pelvic  organs 

„        rectum 
Ligaments.     See  joints. 
Ling's  system 

,,  ,,       literature  about 

Liver,  frictions  of .  . 
,,  hackings  over 
,,  nerves  of  .  . 
„  shaking  of  .  . 
,,  vibration  of 
Locomotor  ataxia 
Locomotor  system,  diseases  of 

Lowered  vitality,  effect  of  nerve  frictions  on  conditions  of 
Lumbago    . . 
Lumbar  region,  hacking  of 

,,         vertebrae,  effect  of  leg  movements  on 
Lungs,  catarrh  of  .  . 

,,       nerves  of    . . 

See  chest  clapping,  chest  expansion, 
Lying  position 

,,  ,,         positions  derived  from 

Lymph  and  lymphatics,  diseases  of 

„  ,,  ,,  effect  of  duplicate  movements  on 

„  ,,  „  „        passive  movements  at  joints ' 

„  ,,  ,,  ,,        respiration  on 

„  „  ,,  ,,        traction  on  .  . 

„         ,,  ,,  „        vibration  and  shaking  on . 

Lymphadenitis.     See  lymphangitis. 
Lymphangitis 


Machine  gymnastics 

,,  vibrations 

Malplacements  of  uterus  . . 
Mammary  gland  abscess,  threatening    . . 
Mania  . . 

Massage,  definition  of 

„        differences  from  Kellgren's  kneadings 

effects  of 

history  and  introduction  into  Sweden 

varieties  of 

a  friction 

abdominal 

eruptions 

for  headache 

for  sciatica 

on  nerves 
Mastoid  vibration 
Maxilla,  inferior,  movements  of  .  . 


PAGE 

..      200 

37 

139,  237 

..     233 

.  .      127 

131,  184 

94 

,  236,  237 

..      233 

2,  3,  6,  7 
6 
232 
201 
164 
232 
232 

161,  393,  394,  396 
461 
153 
463,  465,  466 
201 
60 
329 
164 


14 

23 

382 

32 

on   . .  38,  39 

..125,  126,  127 

27 

. .      183 

..205,382-387 

242,  243 
182,  183,  184,  243 
236 
476 
397 
210 
211 
212 
210 
no,  211.212 
210 
230 
211,212,231 
456 
449 
148 
187 
181,  216 


INDEX   OF   SUBJECTS 


Maxilla,  superior,  shaking  and  vibration  of       . . 

Measles 

Meatus.     See  ear. 

Mechanical  stimulation  of  nerve.     See  nerve  friction,  pressing  and  vi 

Median  nerve  paralysis     . . 

Medical  gymnastics 

Medicinal  treatment  of  nervous  diseases 

,,  ,,  rheumatism 

Mediotarsal  joint.     iSee  tarsal  joints. 
Medulla,  vibration  of 
Melancholia 
Meningitis,  acute  . . 

,,  epidemic  cerebrospinal 

,,  .syphilitic 

Menorrhagia 

Menstruation,  disorders  of 
,,  insanity  of 

,,  treatment  during 

Mental  overstrain  and  overwork 
Metabolism,  effect  of  duplicate  movements  on 

,,  ,,        passive  movements  at  joints  on 

Metacarpo-phalangeal  joints.     See  fingers  and  thumb. 
Metatarso-phalangeal  joints.     See  toes. 
Metrorrhagia 
Middle  ear  disease 
Military  gymnastics 
Mitral  valve  disease  . .  .  .  .  .  .  .  .  .  . .     359, 

Modifications  in  exercises  .  .  .  .  .  .  .  .  3.5,  43, 

Motor  nerves,  effect  of  duplicate  movements  on 
,,  ,,  ,,        nerve  frictions  on 

,,  ,,  .,        passive  movements  at  joints  on 

„  ,,  ,,        pressings  on 

,,  ,,  ,,        traction  on 

,,  ,,  ,,        vibrations  on      . . 

Mo\'ements,  gymnastic,  classification 
,,  ,,  definitions 

,,  ,,  general  directions  for  performing 

See  active,  duplicate,  passive,  respiratory. 
Mumps        .  .       -263,  2(55,  276,  278,  282,  283,  284,  285,  286,  287,  289, 
Muscles,  abdominal.     See  abdominal, 
beating  on 

blood  supply  to  active  and  resting 
efiect  of  duplicate  movements  on 
,,        nerve  frictions  on 
,,        passive  movements  on 
,,        traction  on 
frictions  on 
hacking  over 
kneading  of 
Muscular  sense 

Musculo-spiral  nerve,  gunshot  injury  to 
Myelitis,  spinal 


PAGE 

..      186 

260,  203,  478 


. .      396 

2,  3,  5 

. .      395 

. .      463 

..      185 

. .     397 

..      186 

298,  479 

396,  414 

. .      474 

236,  275,  474 

. .      .397 

. .      236 

.396,  451 

35 

39 


236,  275 

276,  478,  481 

. .      2,  5 

364,  308,  370 

240,  241,  242 

323 

150 

39 

155 

28 

149 

10,  11,  41 

1(1,  11,  12 

43,  44 

290,  478,  479 

. .      204 

28,  29,  30,  31 

34,  35 

150,  151,  152 

38,  39 

27 

194,  195 

..      202 

207-209 

33 

..      460 

..      396 


Neck  bending  and  stretching 

Nerve  or  nerves,  abdominal  sympathetic 

32 


164-169,230 


40H 


INDEX   OF   SUBJECTS 


Nerve  or  nerves,  auricular,  posterior    . . 
auriculo-temporal 
bladder,  sympathetic  of 
brachial  plexus 
bronchi,  sympathetic  of 
cervical,  anterior  branches 

,,         posterior  branches 

„        sympathetic 
circumflex 
coccygeal 

,,  ganglion  (ganglion  impar) 

crural,  anterior 
cutaneous,  external  (of  leg) 
,,  internal  (of  leg) 

„  of  foot 

descending  cervical 
diaphragm,  sympathetic  of 
dorsal    .  . 
eyeball,  of 
eyelids,  of 
facial 

fifth  {see  also  separate  branches) 
foot,  cutaneous  of 
gall-bladder,  sympathetic  of 
ganglion.     See  individual  ganglia  and 

,,  impar 

genital  organs,  syinpathetic  of 
glosso-pharyngeal 
gluteal,  inferior 

,,       superior 
heart,  of 

hypogastric  plexus,  inferior 
hypoglossal 
ilio-hypogastric 
ilio-inguinal 
impar,  ganglion 
infraorbital 
infratrochlear 
intercostal,  in  abdomen 

,,  thorax 

interosseous,  posterior 
intestines,  sympathetic  of 
kidneys,  sympathetic  of 
lachrymal 
laryngeal,  inferior 
,,  superior 

lingual   .  . 

liver,  sympathetic  of 
lumbar  . . 

lungs,  sympathetic  of 
masseter,  of 
med'an  .  . 
mental   .  . 

musculo-cutaneous  (of  leg) 
musculo-spiral 


PAGE 

. .      157 

..173 

165,  168 

IfiO,  170,  396 

.  .      164 

160,  161,  162 

1,  100,  101,  162,213 

.      162 

170 

.      167 

.      166 

.      172 

.      172 

.      174 

72,  174 

.      163 

.      165 

64,  165 

.      158 

.      158 

58,  396 

.      173 

72,  174 

.      164 


.  166 
.  105 
.  159 
.  171 
.  171 
59,  164 
.  169 
.  159 
.  166 
.  166 
.  106 
.  158 
157,  186 
166,  230 
162,  103 
170 
.  165 
.  165 
.  158 
.  159 
.  159 
.  159 
164 
64,  165 
.  164 
.  158 
80,  396 
.  158 
.  172 
70,  460 


170, 


INDEX   OF   SUBJECTS 


499 


PAGE 

Nerve  or  nerves,  nasal 

157,186 

„       „        ,,        obturator 

. .      172 

,       ,,        ,.        occipital,  great 

..      157 

,        „        „               „          small 

..      157 

„        „        optic 

185,  393,  396 

phrenic 

..      159 

,        „        „        plantar,  external 

..172 

„        „              „        internal 

151,  171,  180 

,        „        ,,        popliteal,  external 

..      171 

,        ,,        ,,               ,,          internal 

..      171 

,        „        „        pylorus,  sympathetic  of 

. .      164 

,        „^       „        radial     . . 

150,171 

,        „        „        rectum,  of 

165,  167 

,        ,,        „        renal  plexus 

165,  167 

,        ,,        „        sacral     .  . 

..      163 

,        ,,        ,,        saphenous,  long 

151,172 

„        „                 „           short 

..172 

„        „        sciatic,  great  {see  sciatica) 

58,  171 

,        „        „        sensory  of  foot 

..172 

,        ,,        „        solar  plexus 

. .      167 

„        „        spinal  accessory 

. .      160 

,        „        ,,        splanchnic 

10.5,  166 

„        „        spleen,  sympathetic  of 

.  .      165 

,        ,,        „        stomach,  sympathetic  of 

.  .      164 

„        „        submaxillary  ganglion 

..159 

,       „        „        subtrapezial  plexus 

. .      160 

,       „        „        supraorbital 

..157,  ISO,  447 

,       „        „        suprascapular 

..170 

,       .,        „        supratrochlear 

157,186 

„        „        tempore -facial 

..173 

,        „        „        thoracic,  anterior 

..170 

,       „        „             „         sympathetic . . 

164,  165 

,        „        „        tibial,  anterior 

..171 

„        „            „      posterior 

171 

,        „        „        ulnar 

170,  390 

,        „        „        uterus,  sympathetic  of 

..      105 

,        „        ,,        vagus     .  . 

..159 

See  sympathetic  nerves. 

Nerve  frictions  and  vibrations,  effects  uf,  direct 

149,  150 

»             »           ..             „                  .,          physical 

. .      144 

„             „           „              „                  „         reflex 

150-154 

„              „           „              „          hand  and  foot 

. .      180 

„             „           „              „           hand  to  foot     .  . 

175-179 

„             „          head  to  foot     . . 

175,179 

„             „           „              „           history  and  development 

.  .      144 

„             „           „              „           modus  operandi 

142-144 

„             „           „              „           on  nerves  of  arm 

170,173 

„             ,,           „              „            „         ,,         cerebro-spinal  system 

as  a  whole 

175-179 

„             „           „              „            „         „         head  and  neck 

..157,  &c.,  173 

„         leg 

..171,  172,174 

„             „           „              „            ,,         „         trunk 

102-169 

„           „              ,,           V.  nerve  pressin 

gs 

.  .      155 

See  individual  nerves  and  running. 
Nerve  fiinctionabilitv.  effect  of  nerve  frictions  on 


50U 


INDEX    OF   SUBJECTS 


Nerve  pressings 

Nerve  vibrations,  effects  . . 

„  ,,  history  and  development 

,,  „  modus  operandi 

See  nerve  frictions. 
Nerves,  effect  of  dviplicate  nio\'onients  on 

,,  ,,        nerve  frictions  on 

„  „        passive  movements  at  joints  on 

,,  ,,        pressings  on 

,,  ,,        traction     ,, 

,,  ..        vibrations  on     . . 

,,        motor.     See  motor  nerves. 

,,        sensory.     See  sensory  nerves. 

,,        sympatlietic.     Sec  sympathetic  nerves. 
Sec  aho  nerve  or  nerves  and  nerve  frictions. 
Nervous  diseases,  electrical  and  medicinal  treatment  of 

,,  ,,         functional 

,,  ,,         organic  brain  and  spinal  cord 

„  „        peripheral 

,,  „         sympathetic    .  . 

Neuralgia    . . 
Neurasthenia 

Neuritis  (see  sciatica,  supraorbital) 
Nipping  vibrations 
Non-pregnant  uterus.      See  uterus. 
Nose,  shaking  and  vibration  of  . . 

Occipital  suction  movement 
Occipito-atlantal  joint  [see  head) 
Oertel's  treatment 
Ovaries,  frictions  on 

,,         vibrations  on       . . 

Pancre-\s  .  . 
Paraplegia,  spastic 
Paralysis     .  . 

iS'ee  individual  diseases. 
Paralysis  agitans  .  . 
Parotid  gland.     See  salivary  glands. 
Parotitis 

,.  epidemic.     See  mumps. 

Parturient  uterus,  treatment  of  .  . 
Passive  movements,  definition    . . 

.,  ;,■  at  joints,  effects     . 

,,  ,,  ,,        varieties. 

Pedagogical  gymnastics    .  . 
Pelvic  organs   ■       .  . 

See  also  ovaries,  uterus. 
Pericarditis 
Peritonitis,  acute  .  . 
Perspiration,  effect  of  massage  on 

,,  ,.        nerve  frictions  on 

Petrissage   . . 
Pharynx,  shaking  and  vibration  of 

See  also  throat  exercise. 


PAGE 
144  i48.  155,  l.'je,  159 
144,  149 
144 
..      136 

32,  33 

149-153 

39 

144,  155 

28 

149 


. .  395 
..  394 
. .  391 
..  394 
394,  395 

390,  447-451 
..      396 

396,  447-451 
..      140 


49,  394: 
293,  394. 


..      186 

..  219 
73,  132 
358,  359 
.  .  236 
. .      236 

230,  232 

396,  397 

37 


73,  105,  230.  396 
.  .      479 


237.  238 
13 

.  .  38-40 
13 


59,  91),  127,  160,  204 

370,  479 
165,  230,  341,  480,  482.  483 
211,231 
150,  162 
210,211 
187 


INDEX  OF    SUBJECTS 


501 


Phthisis  pulmonum 
Pit  of  the  stomach,  shaking  of     .  . 
Plantar  reflex.     See  Babinsky.  Kellgren. 
Pleiirisy,  acute 

,,         chronic    .  . 

,,         diaphragmatic   . . 
Plexus.     See  nerve. 
Pneumonia,  acute  croupous 

,,  broncho- 

Polioinyelitis  aaterior  acuta 
PopUteal  vein 
Positions,  definition  of 

„  description 

,,  varieties 

Post-diphtheritic  paralysis 
Post-partura,  treatment  of 
Pregnancy,  treatment  during 
Pressing,  elbow 

,,         knee 

leg  

,,         on  arteries 

,,         on  nerves.     ^S'ee  nerve  pressing. 

,,         on  \'eins 
Pressure  friction    .  . 

,,         vibration 
Principles,  general,  of  treatment 
Prolapse  of  uterus 
Pronation  and  supination  (see  radio-uhiar  joints) 
Prostate  gland 

Psychical  effect  of  gymnastic  movements 
Puerperium,  treatment  during    .  . 
Pupils,  effect  of  nerve  frictions  on 
Purely  active  movements.     >See  acti\'e  movements 
Pylorus,  nerves  of 
Pyrexia.     See  fevei'. 

Radial  flexion 

Radio-ulnar  joints,  pronation  and  supination  .  . 


Raising.     .See  arm,  bacli,  heel,  knee,  leg,  toe.  trunk. 

.,         stride  sit  kneeling 
Raynaud's  disease 
Rectum,  nerves  of 

,,         lifting 
Reflex  arc,  effect  of  movements  at  joints  on 
Resisted  exercises.     Sec  duplicate  movements. 
Respiration  during  gj'mnastic  exercises 

,,  effects  of  duplicate  movements  on 

,,  effects  on  circulation  of  blood 

,,  ,,  flow  of  lymph 

Respiratory  exercises 

See  respiration. 
Respiratory  organs,  diseases  of   .  . 
Rest  in  bed  for  cases  of  fever 


PAGE 

..  150 

,  164, 

168,  230 
. .   192 

311,313,318-320,481 

321-.333 

165,  481 

..   25 

1.311 

316,  481 
481,  483 

396 

437-444 

.  65,  69,  108 

10 

.  .  14-26 

14 

293, 

396,  445 

213,238 

.  .   237 

91,  US 

65 

94 

..   213 

..   213 
..   142 
..   137 
..   249 
.  .   236 

.   49-51,  101 

.  .   233 

33,  392 

.  .   238 

.  .   153 

r^ments 
I,  51.  54, 


56 
..      101 

5,  91,  93,  103 

..  215 
.  .  397 
165,  167 
..  233 
39 


34,  35,  43,  44. 


78,  80,  82,  127 


124 
35 
124 
125 
-130 

311 
252 


502 


INDEX   OF   SUBJECTS 


Retrobulbar  haemorrhage 
Rheumatic  cephalalgia 
„  erythema 

„  fever    . . 

,,  pericarditis 

Rheumatism,  chronic 

„  „  medicinal  treatment  of 

Ringing 

Rolling.     See  circumduction. 
Rotation,  alternate 

,,  of  the  head 

,,  ,,       hip-joint 

,,  ,,       knee-joint 

„  „      shoulder-joint   . . 

„  „       trunk 

,,  ,,       wri.st-joint 

Rotatory  shaking 

,,  vibration 

Running  nerve  frictions    .  . 

,,         nerve  vibrations 

,,  ,,  ,,  exercises  comprising 

,,         vibrations 

Sacbal  beating 

Salivary  glands,  frictions  on 

,,  ,,        siiaking  and  vibration  of 

See  mumps. 
Scarlatina  anginosa  .  .  .  .    2(W,  2139,  270,  '274, 

,,  gravior 

„  simplex 

Schott's  treatment 
Sciatica 

Scoliosis.     See  spinal  curvature 
Screw  turning 
Secondary  positions 

Secretory  effects  produceahle  by  nerve  frictions 
Sensory  nerves,  effect  of  duplicate  movements  on 

„  ,.  „        nerve  frictions  on 

„  „  ,,        passive  movements  at  joints 

„  ,,  ,,        pressings  on     . . 

,,  ,,  ,,        traction  on 

,,  ,,  .,         vibrations  on  .  . 

Sensory-motor  circuit 
Sequelae  of  influenza 
Shaking  and  vibration,  effects     .  . 

,,  ,,  ,,  history  and  development 

,,  ,,  ,,  modus  operandi 

„  ,.  ,,  aroiuid  abscesses 

,,  „  ,,  on  the  abdomen 

-,  ,,  ,,  ,,        anal  canal 

,,  ,,  „  „        anus 

„  ,,  ,,  ,,        appendix 

„  .,  ,.  „        arm 

,,  ,,  ,,  over  the  bladder 

,,  ..  ,,  on  the  coronal  suture   . . 


PAGE 

.  .   396 

479 

300,  479 

300,  479 

370,  479 

305 

461,  466 

..   463 

87 

99 

.  98 

181,  184 

97 

..    98 

97 

99 

97 

..   135 

..   139 

..   143 

..   139 

173-179 

.  .   139 

.  .   203 

..   196 

..   188 

,  282 

284,  478 

27G 

288,  478 

273, 

286,  478 

. .   359 

396, 

448,  450 

..   110 

.  .  16-26 

150,  153 

32 

149,  152 

39 

155 

28 

.  .   149 

32 

454,  455 

..   183 

180,  181 

133-136 

..   193 

..   192 

. .   233 

.  .   233 

.  .   232 

..   189 

168 

169,  233 

.169 

186,  238 

INDEX   OF   SUBJECTS 


503 


PAGE 

Shaking  and  vibration  of 

the  ear 

187 

,        epididymis 

233 

eyes         

185 

,,          „            „ 

,        gall-bladder 

232 

,        head 

181,  18+ 

,        heart 

..190,  191,  192 

»          »            .. 

inferior  maxilla. . 

181 

„          ,,            ,. 

,        intestines 

232 

„          „            .. 

,        joints 

19 1 

,.          „            „ 

,        kidneys  . . 

232 

larynx     . . 

188 

,,          ,,            ,, 

,        lateral  half  of  body 

189 

„          „            „ 

.         leg            ..           ..■         .. 

189 

,,          „            „ 

liver 

232 

»»          »»            0 

,        mastoid . . 

187 

medulla. . 

185 

„          „            „ 

nose 

181,186 

„          „ 

ovaries    .  . 

230 

pharynx 

187 

pit  of  the  stomach 

192 

„          „ 

prostate  gland  .  . 

233 

„ 

,        salivary  glands. . 

1 88 

,        spermatic  cord . . 

233 

spinal  cord 

192 

„ 

spleen     . . 

2.32 

»»          ,,            ,,             , 

,        stomach.  . 

231 

»»          »»            j> 

,        stomach,  pit  of  the 

192 

,        subcostal  triangle 

192 

,. 

superior  maxilla 

180 

,        testicle    . . 

233 

„          ,,            „             , 

thorax    . . 

189 

„          „            „             , 

thyroid  gland     . . 

188 

„          „            „             , 

tonsils     . . 

187,188 

trachea  . . 

188 

trunk 

189 

ulcers 

193 

,        whole  of  body   .  . 

189 

„          „            „ 

wounds  . . 

193 

See  vibration. 

Shoulder  hacking  .  . 

200 

Shoulder-joint,  abduction 

and  adduction  of     .  . 

89-93,  241 

mechanism  of 

89 

,,             ,,     dislocation 

of 

470,  472 

„             .,     eighth  movement  of 

.53,  118 

„            „     flexion  and  extension  of 

45-49 

>i             ..           „         „ 

„          mechanism  of     .  . 

45 

„             .,     rolling  of    . 

103-106 

„             ,,     rotation  of 

97 

Side  length  hacking 

201 

Side  shaking 

189 

Sitting  position 

14 

„         positions 

derived  from 

22 

Skin  secretion 

211,231 

See  perspiration. 

Soles  of  the  feet,  clapping 

on 

203 

S04  INDEX    OF   SUBJECTS 

PAGE 

Sommerbrodt's  reflex        .  .          .  .          .  .          . .          .  .          .  .  . .          .  .        33 

Spasm  of  muscles  from  nerve  irritation .  .           . .           . .           .  .  .  .          394,  39(i 

Spastic  diplegia      . .           . .           .  .           .  .           .  .           .  .           . .  . .          39c,  403 

paraplegia              .  .           . .           .  .           . .           . .           .  .  . .          39G,  397 

Specific  infectious  diseases.     .SVp  individual  diseases. 

Spermatic  cord,  vibrations  and  frictions  of        . .           . .           .  .  .  .           .  .      233 

Spinal  cord,  beating  over              .  .           .  .           . .           . .           .  .  .  .           .  .      204 

„      effect  of  nerve  frictions  on  .  .           ..           ..           ..  149,  &c.,  161,  Ui4 

,.            „        trimk  movements  on        ..           ..           ..  84,85,  100,  122 

,,      elongation  of             . .           .  .           . .           . .           .  .  . .           . .        84 

„      hacking  over.      See  back  and  shoulder  hacking. 

,.      vibration  over           ..           ..           ..           ..           ..  ..           ..192 

,,      compression  of          . .           . .           .  .           .  .           .  .  . .           . .      396 

.,      gunshot  wound  of    ..           ..           ..           ..           ..  161,168,396 

,,      hsemorrhago  and  embolism  of        . .           . .           .  .  .  .          396,  433 

iSee  individual  diseases. 

Spinal  curvatures               . .           .  .      78,  1 95,  250,  329,  332,  333,  396,  425,  429,  433 

Spleen,  frictions  on             .  .           .  .           . .           .  .           .  .           .  .  .  .          232,  358 

,,        hackings  over        .  .           .  .           .  .           . .           .  .           .  .  . .           .  .      201 

„        nerves  of    ..           ..           ..           ..           ..           ..           ..  ..           ..      165 

,,        vibration  on          . .           . .           .  .           .  .           .  .           .  .  .  .           . .      232 

Sprain  of  the  gastrocnemius  muscle        . .           .  .           .  .           .  .  .  .           . .      466 

Stammering            ..           ..           ..           ..           ..           ..           ..  ..           ..168 

Standing  position .  .           . .           .  .           . .           .  .           . .           .  .  .  .           . .        14 

.,                ,,         positions  derived  from          ..           ..           ..  ..           ..        17 

Stationary  nerve  frictions             . .           .  .           .  .           .  .           .  .  . .           . .      143 

„              „      vibrations         ..          ..          ..          ..          ..  ..          ..138 

Stimulation,  electrical,  of  nerve.     See  electrical  stimulation. 

,,  mechanical,  of  nerve.      See  mechanical  stimulation. 

Stomach,  effect  of  stomach  exercise  on               . .           .  .           . .  .  .          229,  230 

,,          exercise,  comparisou  with  other  methods     . .           .  .  .  .           . .      230 

effects  of         228 

„                „        modus  operandi         .  .          .  .          .  .          .  .  .  .          .  .     227 

,.          nerves  of             . .           . .           . .           .  .           .  .           .  .  .  .           .  .      164 

„          shaking  on         . .           . .           . .           . .           . .           .  .  .  .           .  .      231 

,,          vibration  on      . .           .  .           . .           . .           .  .           . .  . .           .  .      231 

Stretching,  arm.     See  arm  stretching. 

„           calf  muscle     ..           ..           ..           ..           ..           ..  ..           ..      215 

tnmk 105 

,,           vertebral  column       ..           ..           ..           ..           ..  ..           ..214 

<See  extension,  traction. 

Stroking,  centrifugal         .  .           .  .           . .           . .           . .           .  .  .  .           . .      205 

,,          centripetal          . .           . .           . .           .  .           . .           .  .  .  .           .  .      205 

effects  of  206 

,,          modus  operandi              . .           . .           . .           . .           .  .  . .           . .      205 

vibratory            140,  205 

Subdural  haemorrhage       .  .           .  .           .  .           .  .           . .           .  .  .  .          396,  407 

Subclavian  vein     .  .           .  .           .  .           . .           .  •           •  •           .  •  ■  .     48,  49,  125 

Subcostal  shaking.  .           ..           ..           ..           ..           ..           ••  ••           •■      192 

Subdiaphragmatic  suction            ..           ..           ..           ..           -.  •.           ..217 

Sublingual  gland.     iS'ee  salivary  glands. 

Submaxillary  gland.     See  salivary  glands. 

Suction,  subdiaphragmatic           .  .           . .           ■ .           •  •           ■  •  •  •           •  •      217 

occipital 219 

,.         vibrations             . .           . .           . .           . .           • .           ■  •  •  •           . .      140 


INDEX    OF   SUBJECTS 


505 


PACK 

Summation  of  stimuli 

1.53,  l.i4 

Superior  longitudinal  sinus 

173 

Supination  and  pronation  {See  radio-ulnar  joints) 

..      4'.t-.-)l,  101 

Supraorbital  neuralgia 

4+7 

Suprapubic  kneading 

234 

„            shaking  and  vibration.     See  bladder 

168,  169,  233 

Swinging,  arm 

49 

..          leg          

61 

Sympathetic  ganglia.     See  nerves. 

„              nerves,  frictions  on 

1.50,  1.-V2,  ]o3 

„                  „              „          „     effects  of 

..      15-2,  1.53,  161,  162 

Synovitis    . . 

37,  467 

Syphilis 

.  .      396,  397,  414,  433 

Tapotement 

197,210 

Tarsal  joints,  flexion  and  extension  of     .  . 

.  .       69-72,  241 

,,            ,,       inversion  and  eversion  of 

102 

„           „       rolling  of     .  . 

109 

Terminology  of  gymnastic  exercises 

42,  43 

„              „            „           positions 

16 

Testicle,  nerves  of . . 

166 

„         vibrations  on      .  . 

233 

Thoracic  duct 

.  .      49,  83,  125 

Thorax,  effect  of  trunk  movements  on  . . 

83,  85 

shaking  of 

189,190 

vibration  of 

190 

Throat.     See  larynx,  pharynx. 

„        exercise     . . 

223 

Thumb,  abduction  and  adduction  of      .  . 

33 

flexion  and  extension  of 

56 

„        rolling  of  . . 

106 

Thyroid  gland,  shaking  and  vibration  of 

.       188 

„             „       exophthalmic  goitre 

.. 

88,  387 

Tic  douloureux 

.      396 

Tight  lacing 

127 

Toe  raising .  . 

80 

Toes,  flexion  and  extension  of      .  . 

72 

„      rolling  of       .  . 

.      110 

Tonsils,  shaking  and  vibration  of 

.  . 

87,  188 

Tonsilitis,  acute 

334,  479,  480 

Trachea,  shaking  and  vibration  of 

188 

Traction,  effects  of 

12,27,28,38 

„         modus  operandi 

12 

„         of  arms  . . 

114,115 

„          „  joints 

..  28,  114,  194 

..          ..leg 

115 

,,  trunk 

115 

,,          and  nerve  friction  simultaneously 

179 

Trunk,  flexion  and  extension  of,  on  hip-joints  . . 

.  .   76,  84-88,  200,  201 

„             „         „               „              on  itself 

76,  80,  200,  201 

„       hacking  on 

200,  201 

„       lateral  flexion  and  extension  of  .  . 

84-88 

„       raising 

67,  93 

rolling  of    . . 

110 

„       rotation  of .  . 

99 

33 


5o6 


INDEX    OF  SUBJECTS 


Trunk  stretching  .  . 

„       traction  of 

„       vibration  on 
Turning.     See  screw  turning  and  rotation. 
Typhoid  fever 

Ulcers,  frictions  round 
„        vibration  over 
Ulnar  flexion 

,,      nerve  paralysis 
Umbilicus  . . 
Uterine  lift  vibration 
Uterus,  nerves  of  . . 

treatment  for  non-pregnant 
,,  „  ,.  .,  frictions     .  . 

„  „  ,.  kneading   .  . 

,,  ,.  ,.  ,,  lifting 

,,  ,,  ..  .,  vibration  . . 

,,  .,  ,,    malplacements  in  non-prognant 

,.   partiu-ient 
,,  ,,    post-partum 

,,  ,.   pregnant  . . 

,,  ,,    prolapse  of 

,.  ..    puerperal 

Vasomotor.     See  blood-vessels. 
Veins,  compression  of 

,.      effect  of  muscular  action  on 
,,  ,,        traction  on 

See  blood-vessels  and  individual  veins. 
Vertebral  column  stretching 
Vibrating  machines 
Vibration  on  nerves  and  ganglia 
,,  on  other  structures 

iSee  shaking  and  nerve  vibration. 
Vibrations,  dispersing 

lift        . .  

nipping 
pressure 
rimning 
stationary 
suction 
friction 
,,  ,.         with  suction .  . 

Vibrator 
Vibratory  stro  kings 

,,  traction 

Visceral  effects  producible  by  nerve  frictions 

Whooping  cough  .  . 
Wide's  modification  of  Ling's  system 
Wounds,  vibrations  over 
Wrist-joint.     See  carpal-joints. 
Writer's  cramp 


PAGE 

.  .      195 
115,  116 

189 

253,  478,  482 

.  .      196 

193 

56 

.  .      396 

166,  167 

139,  237 

.  .      165 

234 

. .      235 

.  .      234 

235,  236 

235,  236 

. .      236 

237,  238 

.  .      238 

. .      237 

236 

.  .      238 


213 

28-31 

28 

214 

.  .      182,  183,  184,  243 

144-180 

18(1-194.  231.  232,  233 


140 

139,  237 
..140 
.137 
..139 
.  .      138 

140 

143 

.143 

182.  183.  184.243 

140,  205 
. .  194 
150,  153 

259.  260.  478,  479 

193 

.  .      396 


London : 
John  Bale,  Sons  &  Danielsson,  Ltd., 

i),  Great  Titchfield  Street,  W. 


UNIVERSITY   OF   CALIFORNIA   LIBRARY 
BERKELEY 


1         THIS  BOOK  IS  BUB  ON  THE  LAST  DATE 
i  STAMPED  BELOW 

I  -  ..      .    ..:..„»  .„   „   finP  of 


RETURN 
TO— ► 

LOAN  PER 


eiOSOENCES 

LIBRARY 
40  Gimniwi  HaB 


642-2531 


ALL  BOOKS  MAY  BE  RECALLED  AFTER  7  DAYS- 
Renewed  books  ore  subject  to  immediate  recall 


DUE  AS  STAMPED  BELOW 

rfttCffissii'tflSS^ 

MAR  0  2  1992 

UNIVERSITY  OF  CALIFORNIA,  BERKELEY 
FORM  NO.  DD4,  12m,  12/80        BERKELEY,  CA  94720 


r 


U.C.  BERKELEY  LIBRARIES 


CDB'iaE^BDa 


y 


358889 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 


